Adira at Riverside Rehabilitation Comprehensive Emergency ... · The facility conducts an annual risk assessment to identify which natural and man-made hazards pose the greatest risk

Adira at Riverside Rehabilitation

Comprehensive Emergency Management Plan Template

Part II – Template

2020

Adira at Riverside Rehabilitation 120 Odell Avenue Yonkers, NY 10701 www.adirariverside.com

New York State | Department of Health

CEMP Template (Part II) - Page 2

Instructions

The NYSDOH Comprehensive Emergency Management (CEMP) Template is a tool to help

facilities develop and maintain facility-specific CEMPs. For 2020, Appendix K has been updated

to include guidance and formatted to provide a form to comply with the new requirements of

Chapter 114 of the Laws of 2020 for the development of a Pandemic Emergency Plan (PEP).The

plan template is designed to help facilities easily identify the information needed to effectively plan

for, respond to, and recover from natural and man-made disasters. All content in this template

should be reviewed and tailored to meet the needs of each facility.

Refer to Part 1 – Instructions for additional information about completion of this template.

Refer to Part 3 – Toolkit for supplementary tools and templates to inform CEMP development and

implementation.



Emergency Contacts

The following table lists contact information for public safety and public health representatives for

quick reference during an emergency.

Table 1: Emergency Contact Information

Organization Phone Number(s)

Local Fire Department

914-723-3430

Local Police Department

914-377-7500

Emergency Medical Services

914-377-4357

Fire Marshal 914-377-7525

Local Office of Emergency Management

914-377-4357

NYSDOH Regional Office (Business Hours)1

914-654-7058

NYSDOH Duty Officer (Business Hours)

866-881-2809

New York State Watch Center (Warning Point)

(Non-Business Hours)

518-292-2200

1 During normal business hours (non-holiday weekdays from 8:00 am – 5:00 pm), contact the NYSDOH Regional Office for your region or the NYSDOH Duty Officer. Outside of normal business hours (e.g., evenings, weekends, or holidays), contact the New York State Watch Center (Warning Point).



Record of Changes

Table 2: Record of Changes

Version

#

Implemented

By

Revision

Date Description of Change

1.0

ADMINISTRATION/

DNS/RDNS

8-26-2020 Reviewed and revised pgs 1-

16 & Annex E.

2.0 ADMINISTRATION 9-1-2020 Pages: 17-37

3.0 ADMINISTRATION,

NURSING, EVS, AND

ENGINGEERING.

9-11-2020 Page 37-end. Complete

review.



Record of External Distribution

Table 3: Record of External Distribution

Date Recipient Name Recipient Organization Format Number of

Copies

September 15

th 2020

Facility website

Adira at Riverside

Rehabilitation

PDF

1



Table of Contents

INSTRUCTIONS 2

EMERGENCY CONTACTS 3

APPROVAL AND IMPLEMENTATION 4

RECORD OF CHANGES 5

RECORD OF EXTERNAL DISTRIBUTION 6

1 BACKGROUND 10

1.1 Introduction 10

1.2 Purpose 10

1.3 Scope 11

1.4 Situation 12

1.4.1 Risk Assessment 12

1.4.2 Mitigation Overview 13

1.5 Planning Assumptions 13

2 CONCEPT OF OPERATIONS 14

2.1 Notification and Activation 14

2.1.1 Hazard Identification 14

2.1.2 Activation 14

2.1.3 Staff Notification 15

2.1.4 External Notification 15

2.2 Mobilization 17

2.2.1 Incident Management Team 17

2.2.2 Command Center 19

2.3 Response 19

2.3.1 Assessment 19

2.3.2 Protective Actions 19

2.3.3 Staffing 19

2.4 Recovery 20

2.4.1 Recovery Services 20

2.4.2 Demobilization 21

2.4.3 Infrastructure Restoration 21

2.4.4 Resumption of Full Services 22

2.4.5 Resource Inventory and Accountability 22

3 INFORMATION MANAGEMENT 23

3.1 Critical Facility Records 23



3.2 Resident Tracking and Information-Sharing 23

3.2.1 Tracking Evacuated Residents 23

3.3 Staff Tracking and Accountability 24

3.3.1 Tracking Facility Personnel 24

3.3.2 Staff Accountability 24

3.3.3 Non-Facility Personnel 24

4 COMMUNICATIONS 25

4.1 Facility Communications 25

4.1.1 Communications Review and Approval 25

4.2 Internal Communications 26

4.2.1 Staff Communication 26

4.2.2 Staff Reception Area 26

4.2.3 Resident Communication 26

4.3 External Communications 27

4.3.1 Corporate/Parent Organization 27

4.3.2 Authorized Family and Guardians 27

4.3.3 Media and General Public 28

5 ADMINISTRATION, FINANCE, LOGISTICS 29

5.1 Administration 29

5.1.1 Preparedness 29

5.2 Finance 29


5.2.2 Incident Response 29

5.3 Logistics 30


5.3.2 Incident Response 30

6 PLAN DEVELOPMENT AND MAINTENANCE 31

7 AUTHORITIES AND REFERENCES 32

ANNEX A: PROTECTIVE ACTIONS 35

ANNEX B: RESOURCE MANAGEMENT 37

1. Preparedness 37

2. Resource Distribution and Replenishment 37

3. Resource Sharing 38

4. Emergency Staffing 38

ANNEX C: EMERGENCY POWER SYSTEMS 41

1. Capabilities 41

2. Resilience and Vulnerabilities 41



ANNEX D: TRAINING AND EXERCISES 42

1. Training 42

2. Exercises 43

3. Documentation 43

3.1. Participation Records 43

3.2. After Action Reports 43

ANNEX E: [HAZARD] CHECKLIST 44



1 Background

1.1 Introduction

To protect the well-being of residents, staff, and visitors, the following all-hazards Comprehensive

Emergency Management Plan (CEMP) has been developed and includes considerations

necessary to satisfy the requirements for a Pandemic Emergency Plan (PEP). Appendix K of the

CEMP has been adjusted to meet the needs of the PEP and will also provide facilities a form to

post for the public on the facility's website, and to provide immediately upon request. The CEMP

is informed by the conduct of facility-based and community-based risk assessments and

pre- disaster collaboration with Westchester county OEM, Fire and Police Department.

This CEMP is a living document that will be reviewed annually, at a minimum, in accordance with

Section 7: Plan Development and Maintenance.

1.2 Purpose

The purpose of this plan is to describe the facility’s approach to mitigating the effects of, preparing

for, responding to, and recovering from natural disasters, man-made incidents, and/or facility

emergencies.



Mitigation

Prevention of

anticipated

emergencies

or minimizing

their impact

Preparation to

address an

emergency

Preparedness

Recovery

Recovering in the

short,

intermediate, and

long-term from an

emergency

Response

Responding

efficiently and

safely to an

emergency

Figure 1: Four Phases of Emergency Management

1.3 Scope

The scope of this plan extends to any event that disrupts, or has the potential to significantly

disrupt, the provision of normal standards of care and/or continuity of operations, regardless of

the cause of the incident (i.e., man-made or natural disaster).

The plan provides the facility with a framework for the facility’s emergency preparedness program

and utilizes an all-hazards approach to develop facility capabilities and capacities to address

anticipated events.



1.4 Situation

1.4.1 Risk Assessment2

The facility conducts an annual risk assessment to identify

which natural and man-made hazards pose the greatest risk

to the facility (i.e., human and economic losses based on the

vulnerability of people, buildings, and infrastructure).

The facility conducted a facility-specific risk assessment on

8-31-2020 and determined the following hazards may affect

the facility’s ability to maintain operations before, during,

and after an incident:

HVA is completed and reviewed with the IDT.

This risk information serves as the foundation for the plan—including associated policies,

procedures, and preparedness activities.

2 The Hazard Vulnerability Analysis (HVA) is the industry standard for assessing risk to healthcare facilities. Facilities may rely on a community-based risk assessment developed by public health agencies, emergency management agencies, and Health Emergency Preparedness Coalition or in conjunction with conducting its own facility-based assessment. If this approach is used, facilities are expected to have a copy of the community-based risk assessment and to work with the entity that developed it to ensure that the facility’s emergency plan is in alignment.



1.4.2 Mitigation Overview

The primary focus of the facility’s pre-disaster mitigation efforts is to identify the facility’s level of

vulnerability to various hazards and mitigate those vulnerabilities to ensure continuity of service

delivery and business operations despite potential or actual hazardous conditions.

To minimize impacts to service delivery and business operations during an emergency, the facility

has completed the following mitigation activities:

Development and maintenance of a CEMP;

Procurement of emergency supplies and resources;

Establishment and maintenance of mutual aid and vendor agreements to provide

supplementary emergency assistance;

Regular instruction to staff on plans, policies, and procedures; and

Validation of plans, policies, and procedures through exercises.3

For more information about the facility’s fire prevention efforts (e.g., drills), safety

inspections, and equipment testing, please refer to the facility fire safety protocol.

1.5 Planning Assumptions

This plan is guided by the following planning assumptions:

Emergencies and disasters can occur without notice, any day, and on any shift.

Emergencies and disasters may be facility-specific, local, regional, or state-wide.

Local and/or state authorities may declare an emergency.

The facility may receive requests from other facilities for resource support (supplies,

equipment, staffing, or to serve as a receiving facility).

Facility security may be compromised during an emergency.

The emergency may exceed the facility’s capabilities and external emergency resources

may be unavailable. The facility is expected to be able to function without an influx of

outside supplies or assistance for 72 hours.

Power systems (including emergency generators) could fail.

During an emergency, it may be difficult for some staff to get to the facility, or alternately,

they may need to stay in the facility for a prolonged period of time.

3 Refer to the ―Training and Exercises‖ section of this plan for additional information about pre-incident trainings and exercises.



2 Concept of Operations

2.1 Notification and Activation

2.1.1 Hazard Identification

The facility may receive advance warning about an impending natural disaster (e.g., hurricane

forecast) or man-made threat (e.g., law enforcement report), which will be used to determine initial

response activities and the movement of personnel, equipment, and supplies. For no-notice

incidents (e.g., active shooter, tornado), facilities will not receive advance warning about the

disaster, and will need to determine response activities based on the impact of the disaster.

The Incident Commander may designate a staff member to monitor evolving conditions, typically

through television news, reports from government authorities, and weather forecasts.

All staff have a responsibility to report potential or actual hazards or threats to their direct

supervisor.

2.1.2 Activation

Upon notification of hazard or threat—from staff, residents, or

external organizations—the senior-most on-site facility official

will determine whether to activate the plan based on one or

more of the triggers below:

The provision of normal standards of care and/or

continuity of operations is threatened and could

potentially cause harm.

The facility has determined to implement a protective action.

The facility is serving as a receiving facility.

The facility is testing the plan during internal and external exercises (e.g., fire drills).

If one or more activation criteria are met and the plan is activated, the senior-most on-site facility

official—or the most appropriate official based on the incident—will assume the role of ―Incident

Commander‖ and operations proceed as outlined in this document.



2.1.3 Staff Notification

Once a hazard or threat report has been made, an initial notification message will be disseminated

to staff in accordance with the facility’s communication plan.

Department Managers or their designees will contact on-duty personnel to provide additional

instructions and solicit relevant incident information from personnel (e.g., status of residents,

status of equipment).

Once on-duty personnel have been notified, Department Managers will notify off-duty personnel

if necessary and provide additional guidance/instruction (e.g., request to report to facility).

Department personnel are to follow instructions from Department Managers, keep lines of

communication open, and provide status updates in a timely manner.

2.1.4 External Notification

Depending on the type and severity of the incident, the facility may also notify external parties

(e.g., local office of emergency management, resource vendors, relatives and responsible parties)

utilizing local notification procedures to request assistance (e.g., guidance, information,

resources) or to provide situational awareness.

The NYSDOH Regional Office is a mandatory notification recipient regardless of hazard type,

while other notifications may be hazard-specific. Table 4 provides a comprehensive list of

mandatory and recommended external notification recipients based on hazard type.



m e d n a P

Table 4: Notification by Hazard Type

No

tifi

cati

on

Re

cip

ien

t

X=no

Y=yes

M = Mandatory

R = Recommended

Exam

ple

Hazard

Acti

ve T

hre

at4

Blizzard

/Ic

e S

torm

Co

asta

l S

torm

Dam

Failu

re

Wate

r D

isru

pti

on

Eart

hq

ua

ke

Extr

em

e C

old

Extr

em

e H

eat

Fir

e

Flo

od

CB

RN

E5

Infe

ctio

us D

ise

ase /

Lan

dslid

e

IT/C

om

ms F

ail

ure

Po

wer

Ou

tag

e

To

rnad

o

Wild

fire

NYSDOH Regional

Office6 M M M M M M M M M M M

M

M M M M M

Facility Senior

Leader M X X X X X X X X X X Y M X X X X X

Local Emergency

Management R X X X X X X X X X X Y Y X X X X X

Local Law

Enforcement

Y X X X X X X X Y X Y X X X X X X

Local Fire/EMS

Y X X Y X X X X Y X Y Y X X X X X

Local Health

Department R Y X X X Y Y X X Y X Y M X X Y Y Y

Off Duty Staff

Y X X X X X X X X X Y Y X X X X X

Relatives and

Responsible

Parties

Y

X

X

X

X

X

X

X

Y

X

Y

M

X

Y

X

X

X

Resource Vendors

Y X X X X X X X X X Y Y X X X X X

Authority Having

Jurisdiction

Y X X X Y X X X X Y Y Y X Y Y X X

Regional

Healthcare Facility

Evacuation Center

Y

X

X

X

X

Y

Y

Y

Y

Y

X

Y

X

X

Y

X

X

4 ―Active threat‖ is defined as an individual or group of individuals actively engaged in killing or attempting to kill people in a populated area. Example attack methods may include bombs, firearms, and fire as a weapon.

5 ―CBRNE‖ refers to ―Chemical, Biological, Radiological, Nuclear, or Explosive‖

6 To notify NYSDOH of an emergency during business hours (non-holiday weekdays from 8:00 am – 5:00 pm), the Incident Commander will contact the NYSDOH Regional Office 212-417-4440 Outside of normal business hours (e.g., evenings, weekends, or holidays), the Incident Commander will contact the New York State Watch Center (Warning Point) at 518- 292-2200. The Watch Command will return the call and will ask for the type of emergency and the type of facility (e.g. hospital, nursing home, adult home) involved. The Watch Command will then route the call to the Administrator on Duty, who will assist the facility with response to the

situation.



2.2 Mobilization

2.2.1 Incident Management Team

Upon plan activation, the Incident Commander will activate some or all positions of the Incident

Management Team, which is comprised of pre-designated personnel who are trained and

assigned to plan and execute response and recovery operations.

Incident Management Team activation is designed to be

flexible and scalable depending on the type, scope, and

complexity of the incident. As a result, the Incident

Commander will decide to activate the entire team or select

positions based on the extent of the emergency.

Table 5 outlines suggested facility positions to fill each of the

Incident Management Team positions. The most appropriate

individual given the event/incident may fill different roles as

needed.

Table 5: Incident Management Team - Facility Position Crosswalk

Incident Position Facility Position Title Description

Incident

Commander

Administrator

Leads the response and activates and

manages other Incident Management

Team positions.

Public

Information

Officer

Administrator

Director of Social Services Admissions Director

Provides information and updates to

visitors, relatives and responsible

parties, media, and external

organizations.

Safety Officer

Director of Maintenance

Ensures safety of staff, residents, and

visitors; monitors and addresses

hazardous conditions; empowered to

halt any activity that poses an immediate

threat to health and safety.

Operations

Section Chief

Director of Nursing/ADNS/ RN

supervisor, licensed nurses, ICP.

Manages tactical operations executed by

staff (e.g., continuity of resident services,

administration of first aid).



Direct

Incident Position Facility Position Title Description

Planning

Section Chief

DNS/ADNS

Collects and evaluates information to

support decision-making and maintains

incident documentation, including

staffing plans.

Logistics

Section Chief

Director of Admissions

Director of Social Services Administrator

Medical Records

Locates, distributes, and stores

resources, arranges transportation, and

makes alternate shelter arrangements

with receiving facilities.

Finance/Admin

Section Chief

Finance Manager

Monitors costs related to the incident

while providing accounting, procurement,

time recording, and cost analyses.

If the primary designee for an Incident Management Team position is unavailable, Table 6

identifies primary, secondary, and tertiary facility personnel that will staff Incident Management

Team positions.

While assignments are dependent upon the requirements of the incident, available resources,

and available personnel, this table provides initial options for succession planning, including shift

changes.

Table 6: Orders of Succession

Incident Position Primary Successor 1 Successor 2

Incident Commander Administrator DNS ADNS

Public Information Officer Administrator Director of

Admissions Admissions Coordinator/Dir. of SS

Safety Officer Director of Maintenance

Director of EVS Administrator

Operations Section Chief DNS ADNS Medical Director/RN

Supervisor/licensed nurses.

Planning Section Chief DNS ADNS Medical Director RN

Supervisor/licensed nurses.

Logistics Section Chief Director of Admission Director of Social

Services Social worker

Finance/Admin Section Chief Finance Manager Controller Director of Purchasing



2.2.2 Command Center

The Incident Commander will designate a space, e.g., facility conference room or other large

gathering space, on the facility premises to serve as the centralized location for incident

management and coordination activities, also known as the ―Command Center.‖

The designated location for the Command Center is ADMINISTRATOR’S OFFICE and the

secondary/back-up location is the MAIN DINING ROOM on the first floor unless

circumstances of the emergency dictate the specification of a different location upon activation

of the CEMP, in which case staff will be notified of the change at time of activation

.

2.3 Response

2.3.1 Assessment

The Incident Commander will convene activated Incident Management Team members in the

Command Center and assign staff to assess designated areas of the facility to account for

residents and identify potential or actual risks, including the following:

Number of residents injured or affected;

Status of resident care and support services;

Extent or impact of the problem (e.g., hazards, life safety concerns);

Current and projected staffing levels (clinical, support, and supervisory/managerial);

Status of facility plant, utilities, and environment of care;

Projected impact on normal facility operations;

Facility resident occupancy and bed availability;

Need for protective action; and

Resource needs.

2.3.2 Protective Actions

Refer to Annex A: Protective Actions for more information.

2.3.3 Staffing

Based on the outcomes of the assessment, the Planning Section Chief will develop a staffing plan

for the operational period (e.g., remainder of shift). The Operation Section Chief will execute the

staffing plan by overseeing staff execution of response activities. The Finance/Administration

Section Chief will manage the storage and processing of timekeeping and related documentation

to track staff hours.



2.4 Recovery

2.4.1 Recovery Services

Recovery services focus on the needs of residents and staff and help to restore the facility’s pre-

disaster physical, mental, social, and economic conditions.

Recovery services may include coordination with government, non-profit, and private sector

organizations to identify community resources and services (e.g., employee assistance programs,

state and federal disaster assistance programs, if eligible). Pre-existing facility- and community-

based services and pre-established points of contact are provided in Table 8.

Table 7: Pre-Identified Recovery Services

Service Description of Service Point(s) of Contact

Administration/ Dir of Maintenance

Evaluate life safety of the

Facility.

Sanitarium/ OEM/DOH

Finance Department

Ensure facility is

economically prepared to

open.

Accountants/ CFO

Nursing/social service Department

. Ensure all residents

mental and social needs

are met.

DNS/ Director of SS

Ongoing recovery activities, limited staff resources, as well as the incident’s physical and mental

health impact on staff members may delay facility staff from returning to normal job duties,

responsibilities, and scheduling.

Resuming pre-incident staff scheduling will require a planned transition of staff resources,

accounting for the following considerations:

Priority staffing of critical functions and services (e.g., resident care services,

maintenance, dining services).

Personal staff needs (e.g., restore private residence, care for relatives, attend

memorial services, mental/behavioral health services).

Continued use or release of surge staffing, if activated during incident.



2.4.2 Demobilization

As the incident evolves, the Incident Commander will begin to develop a demobilization plan that

includes the following elements:

Activation of re-entry/repatriation process if evacuation

occurred;7

Deactivation of surge staffing;

Replenishment of emergency resources;

Reactivation of normal services and operations; and

Compilation of documentation for recordkeeping

purposes.

2.4.3 Infrastructure Restoration

Once the Incident Commander has directed the transition from incident response operations to

demobilization, the facility will focus on restoring normal services and operations to provide

continuity of care and preserve the safety and security of residents.

Table 9 outlines entities responsible for performing infrastructure restoration activities and related

contracts/agreements.

Table 8: Infrastructure Restoration Activities

Activity Responsible Entity Contracts/Agreements

Internal assessment of

electrical power.

Dir. of Maintenance

N/A

Clean-up of facility grounds

(e.g., general housekeeping,

removing debris and

damaged materials).

Maintenance/EVS

N/A

Internal damage

assessments (e.g., structural,

environmental, operational).

Director of Maintenance/EVS

N/A

Clinical systems and

equipment inspection.


N/A

7 Refer to the NYSDOH Evacuation Plan Template for more information about repatriation.



Activity Responsible Entity Contracts/Agreements

Strengthen infrastructure for

future disasters (if

repair/restoration activities

are needed).

Director of Maintenance/safety

team

N/A

Communication and

transparency of restoration

efforts to staff and residents.

Director of Social Services/

admissions

Robocalls/ telephone calls/ Letters/Social Media/Email/Website , as deemed needed.

Recurring inspection of

restored structures.

Director of

Maintenance/safety team

N/A

2.4.4 Resumption of Full Services

Department Managers will conduct an internal assessment of the status of resident care services

and advise the Incident Commander and/or facility leadership on the prioritization and timeline of

recovery activities.

Special consideration will be given to services that may require extensive inspection due to safety

concerns surrounding equipment/supplies and interruption of utilities support and resident care

services that directly impact the resumption of services (e.g., food service, laundry).

Staff, residents, and relatives/responsible parties will be notified of any services or resident care

services that are not available, and as possible, provided updates on timeframes for resumption.

The Planning Section Chief will develop a phased plan for resumption of pre-incident staff

scheduling to help transition the facility from surge staffing back to regular staffing levels.

2.4.5 Resource Inventory and Accountability

Full resumption of services involves a timely detailed inventory assessment and inspection of all

equipment, devices, and supplies to determine the state of resources post-disaster and identify

those that need repair or replacement.

All resources, especially resident care equipment, devices, and supplies, will be assessed for

health and safety risks. Questions on resource damage or potential health and safety risks will be

directed to the original manufacturer for additional guidance.



3 Information Management

3.1 Critical Facility Records

Critical facility records that require protection and/or transfer during an incident include:

The facility utilizes Sigma Care EMR. We also have a backup system called Sigma Safe that

can be utilized from a main central computer located in the basement.

If computer systems are interrupted or non-functional, the facility will utilize paper-based

recordkeeping in accordance with internal facility procedures. As per our Disaster plan, critical

Facility records include but are not limited to: Medical and Treatment Orders and Face Sheet .

3.2 Resident Tracking and Information-Sharing

3.2.1 Tracking Evacuated Residents

The facility will use the New York State Evacuation of Facilities in Disasters System (―eFINDS‖)8

and the Resident Evacuation Critical Information and Tracking Form9 to track evacuated residents

and ensure resident care is maintained.

Resident Confidentiality

The facility will ensure resident confidentiality throughout the evacuation process in

accordance with the Health Insurance Portability and Accountability Act Privacy Rule

(Privacy Rule), as well as with any other applicable privacy laws. Under the Privacy Rule,

covered health care providers are permitted to disclose protected health information to

public health authorities authorized by law to collect protected health information to

control disease, injury, or disability, as well as to public or private entities authorized by

law or charter to assist in disaster relief efforts. The Privacy Rule also permits disclosure

of protected health information in other circumstances.

8 eFINDS is a secure, confidential system intended to provide authorized users with real-time access to the location of residents evacuated during an emergency event. The system is to be used to log and track residents during an urgent or non-emergent evacuation. See Appendix K of the NYSDOH Evacuation Plan Template for further information and procedures on eFINDS.

99 The Resident Evacuation Critical Information and Tracking Form is a standardized form utilized to provide pertinent individual

resident information to receiving facilities and provide redundant tracking during the evacuation process, including repatriation. See

Appendix L of the NYSDOH Evacuation Plan Template for the complete form.

10 see HIPAA privacy rule information in CEMP toolkit, Annex K) or: https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/emergency/hipaa-privacy-emergency-situations.pdf

http://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/emergency/hipaa-privacy-emergency-situations.pdf



Private counsel should be consulted where there are specific questions about resident

confidentiality.

3.3 Staff Tracking and Accountability

3.3.1 Tracking Facility Personnel

The facility will use the New York State Evacuation of Facilities in Disasters System (―eFINDS‖)10

and the Resident Evacuation Critical Information and Tracking Form11 to track staff.

3.3.2 Staff Accountability

Staff accountability enhances site safety by allowing the facility to track staff locations and

assignments during an emergency. Staff accountability procedures will be implemented as soon

as the plan is activated.

The facility will utilize staffing sheets on maintained for all nursing staff locations. The

remainder of the departments have specific locations that they are responsible for and

are present at while working. This will track the arrival and departure times of staff.

During every operational period (e.g., shift change), Department Managers or designees

will conduct an accountability check to ensure all on-site staff are accounted for.

If an individual becomes injured or incapacitated during response operations, Department

Managers or designees will notify the Incident Commander to ensure the staff member’s status

change is reflected. An work related injury form will be completed and maintained by HR.

3.3.3 Non-Facility Personnel

The Incident Commander—or Logistics Section Chief, if

activated—will ensure that appropriate credentialing and

verification processes are followed. Throughout the

response, the Incident Commander—or Planning Section

Chief, if activated—will track non-facility personnel providing

surge support along with their respective duties and the

number of hours worked.

10 eFINDS is a secure, confidential system intended to provide authorized users with real-time access to the location of residents evacuated during an emergency event. The system is to be used to log and track residents during an urgent or non-emergent evacuation. See Appendix K of the NYSDOH Evacuation Plan Template for further information and procedures on eFINDS.

11 The Resident Evacuation Critical Information and Tracking Form is a standardized form utilized to provide pertinent individual resident information to receiving facilities and provide redundant tracking during the evacuation process, including repatriation. See Appendix L of the NYSDOH Evacuation Plan Template for the complete form.



4 Communications

4.1 Facility Communications

As part of CEMP development, the facility conducted a

communications assessment to identify existing facility

communications systems, tools, and resources that can be

leveraged during an incident and to determine where

additional resources or policies may be needed.

Primary (the best and intended option) and alternate (secondary back-up option) methods of

communication are outlined in Table 9.

Table 9: Methods of Communication

Mechanism Primary Method of

Communication

Alternate Method of

Communication

Landline telephone

YES

Cell Phone

YES

Voice over Internet Protocol (VOIP)

N/A

Text Messages

YES

Email

YES

News Media

YES

Radio Broadcasts

N/A

Social Media

YES

YES

Runners

N/A

Weather Radio

N/A

Emergency Notification Systems12

YES

Facility Website YES

4.1.1 Communications Review and Approval The facility utilizes robocall to convey messages to both residents, family members and staff in a timely manner.

12 An emergency notification system is a one-way broadcast, sometimes coordinated by a third-party vendor, and is not required by NYSDOH.



Upon plan activation, the Incident Commander may designate a staff member as the Public

Information Officer to serve as the single point of contact for the development, refinement, and

dissemination of internal and external communications.

Key Public Information Officer functions include:

Develops and establishes mechanisms to rapidly receive and transmit information to local

emergency management;

Develops situational reports/updates for internal audiences (staff and residents) and

external audiences;

Develops coordinated, timely, consistent, and reliable messaging and/or tailor pre-scripted

messaging;

Conducts direct resident and relative/responsible party outreach, as appropriate; and

Addresses rumors and misinformation.

4.2 Internal Communications

4.2.1 Staff Communication

The facility maintains a staff listing of all staff members, including emergency contact

information, in the business office to prepare for impacts to communication systems, the facility

also maintains redundant forms of communication with on-site and off-site staff. The facility will

ensure that all staff are familiar with internal communication equipment, policies, and

procedures. The facility utilizes either or robocalls, phone calls, texting and emails to staff

when information is needed to be communicated in a timely manner.

4.2.2 Staff Reception Area

Depending on the nature of the incident, the facility may choose to establish a staff reception area

(e.g., in a break room or near the time clock) to coordinate and check-in staff members as they

arrive to the facility to support incident operations.

The staff reception area also provides a central location where staff can receive job assignments,

checklists, situational updates, and briefings each time they report for their shift. Implementing a

sign-in/sign-out system at the staff reception area will ensure full staff accountability. The staff

reception area also provides the Incident Commander with a central location for staffing updates

and inquiries.



4.2.3 Resident Communication

Upon admission, annually, and prior to any recognized threat, the facility will educate residents

and responsible parties on the CEMP efforts. Resident communication may include resident

counsel meeting, signage, robo calls amongst others

During and after an incident, the Incident Commander—or Public Information Officer, if

activated—will establish a regular location and frequency for delivering information to staff,

residents, and on-site responsible parties (e.g., set times throughout the day), recognizing that

message accuracy is a key component influencing resident trust in the facility and in perceptions

of the response and recovery efforts.

Communication will be adapted, as needed, to meet population-specific needs, including memory-

care residents, individuals with vision and/or hearing impairments, and individuals with other

access and functional needs.

4.3 External Communications

Under no circumstances will protected health information be

released over publicly-accessible communications or media

outlets. All communications with external entities shall be in

plain language, without the use of codes or ambiguous

language.

4.3.1 Corporate/Parent Organization

The facility will coordinate all messaging with SBM Management to ensure external

communications are in alignment with corporate policies, procedures, and brand standards.

Prior to an incident, the facility will coordinate with SBM Management to ensure an on-site

facility staff member(s) has authorization and approval to disseminate messages.

4.3.2 Authorized Family and Guardians

The facility maintains an updated list of all identified authorized family member’s, surrogates and

guardian’s (responsible parties’) contact information, including phone numbers, addresses

and email addresses with Administration/ social services/ admissions. Such individuals

will receive information about the facility’s preparedness efforts upon admission.

During an incident, the facility will notify responsible parties about the incident, status of the

resident, and status of the facility by robocalls. Additional updates may be provided on a regular

basis to keep residents relatives/responsible parties apprised of the incident and the response.

The initial notification message to residents’ primary point of contact (e.g., relative) will include

the following information:



Nature of the incident;

Status of resident;

Restrictions on visitation; and

Estimated duration of protective actions

When incident conditions do not allow the facility to contact residents’ relatives/responsible parties

in a timely manner, or if primary methods of communication are unavailable, the facility will utilize

local or state health officials, the facility website, and/or a recorded outgoing message on

voicemail, among other methods, to provide information to families on the status and location of

residents.

4.3.3 Media and General Public

During an emergency, the facility will utilize traditional media

(e.g., television, newspaper, radio) and social media (e.g.,

Facebook, Twitter) to keep relatives and responsible parties

aware of the situation and the facility’s response posture.

The Incident Commander—or Public Information Officer, if

activated—may assign a staff member to monitor the facility’s

social media pages and email account to respond to inquiries

and address any misinformation.



5 Administration, Finance, Logistics

5.1 Administration

5.1.1 Preparedness

As part of the facility’s preparedness efforts, the facility conducts the following tasks:

Identify and develop roles, responsibilities, and delegations of authority for key decisions

and actions including the approval of the CEMP;

Ensure key processes are documented in the CEMP;

Coordinate annual CEMP review, including the Annexes for all hazards;

Ensure CEMP is in compliance with local, state, and federal regulations; and

5.2 Finance

5.2.1 Preparedness

The finance department will maintain a list of expenses and invoices associated with ensuring the facility and residents are properly cared for and all needs are being met.

5.2.2 Incident Response

Financial functions during an incident include tracking of personnel time and related costs,

initiating contracts, arranging for personnel-related payments and Workers’ Compensation,

tracking of response and recovery costs, and payment of invoices.

The Finance/Administration Section Chief or designee will account for all direct and indirect

incident-related costs from the outset of the response, including:

Personnel (especially overtime and supplementary staffing)

Event-related resident care and clinical support activities

Incident-related resources

Equipment repair and replacement

Costs for event-related facility operations

Vendor services

Personnel illness, injury, or property damage claims

Loss of revenue-generating activities

Cleanup, repair, replacement, and/or rebuild expenses



5.3 Logistics

5.3.1 Preparedness

Logistics functions prior to an incident include identifying and monitoring emergency resource

levels, and executing mutual aid agreements, resource service contracts, and memorandums of

understanding. These functions will be carried out pre-incident by the Administrator or their

designee.

5.3.2 Incident Response

To assess the facility’s logistical needs during an incident, the Logistics Section Chief or designee

will complete the following:

Regularly monitor supply levels and anticipate resource needs during an incident;

Identify multiple providers of services and resources to have alternate options in case of

resource or service shortages; and

Coordinate with the Finance Section Chief to ensure all resource and service costs are

being tracked.

Restock supplies to pre-incident preparedness levels,

Coordinate distribution of supplies to service areas.



6 Plan Development and Maintenance

To ensure plans, policies, and procedures reflect facility-specific needs and capabilities, the

facility will conduct the following activities:

Table 10: Plans, Policies, and Procedures

Activity Led By Frequency

Review and update the facility’s risk

assessment.

Administration

Annually and on-going

Review and update contact information

for response partners, vendors, and

receiving facilities.

Finance Manager/IT

Director

Annually or as response

partners, vendors, and

host facilities provide

updated information.


for staff members and residents’

emergency contacts.

HR/ social services/admissions

director

Annually or as staff

members provide updated

information.


for residents’ point(s) of contact (i.e.,

relatives/responsible parties).

Social services

director /admissions

At admission/readmission,

at each Care Plan Meeting,

and as residents, relatives,

and responsible parties

provide updated

information.

Post clear and visible facility maps

outlining emergency resources at all

nurses’ stations, staff areas, hallways,

and at the front desk.

Director of

Maintenance

Annually and PRN

Maintain electronic versions of the CEMP

in folders/drives that are accessible by

others.

Director of

Maintenance

Annually & as needed

Revise CEMP to address any identified

gaps.

Administration

Upon completion of

an exercise or real-

world incident.

Inventory emergency supplies (e.g.,

potable water, food, resident care

supplies, communication devices,

batteries, flashlights,

Director of

Maintenance/ Director of Dietary

Quarterly & as needed



7 Authorities and References

This plan may be informed by the following authorities and references:

Robert T. Stafford Disaster Relief and Emergency Assistance Act (Public Law 93-288, as

amended, 42 U.S.C. 5121-5207)

Title 44 of the Code of Federal Regulations, Emergency Management and Assistance

Homeland Security Act (Public Law 107-296, as amended, 6 U.S.C. §§ 101 et seq.)

Homeland Security Presidential Directive 5, 2003

Post-Katrina Emergency Management Reform Act of 2006, 2006

National Response Framework, January 2016

National Disaster Recovery Framework, Second Edition, 2016

National Incident Management System, 2017

Presidential Policy Directive 8: National Preparedness, 2011

CFR Title 42, Chapter IV, Subchapter G, Part 483, Subpart B, Section 483.73, 2016

Pandemic and All-Hazards Preparedness Act (PAHPA) of 2006

March 2018 DRAFT Nursing Home Emergency Operations Plan – Evacuation

NYSDOH Healthcare Facility Evacuation Center Manual

Nursing Home Incident Command System (NHICS) Guidebook, 2017

Health Insurance Portability and Accountability Act (HIPAA) of 1996, Privacy Rule

NYSDOH Healthcare Facility Evacuation Center Metropolitan Area Regional Office

Region Facility Guidance Document for the 2017 Coastal Storm Season

NFPA 99 – Health Care Facilities Code, 2012 edition and Tentative Interim Amendments

12-2, 12-3, 12-5, and 12-6

NFPA 101 – Life Safety Code, 2012 edition and Tentative Interim Amendments 12-1, 12-

2, 12-3, and 12-4

NFPA 110 – Standard for Emergency and Standby Power Systems, 2010 edition and

Tentative Interim Amendments to Chapter 7

10 NYCRR Parts 400 and 415

NYS Exec. Law, Article 2-B

Public Health Service Act (codified at 42 USC §§ 243, 247d, 247d-6b, 300hh-10(c)(3)(b),

311, 319)

Cybersecurity Information Sharing Act of 2015 (Pub. L. No. 114-113, codified at 6 U.S.C. §§ 1501 et seq.)

Chapter 114 of the Laws of New York 2020.



An



Annex A: Protective Actions

The Incident Commander may decide to implement protective actions for an entire facility or

specific populations within a facility. A brief overview of protective action options is outlined in

Table 11. For more information, refer to the NYSDOH Evacuation Plan Template, NYSDOH

Healthcare Facility Evacuation Center Metropolitan Area Regional Office Region Facility

Guidance Document for the 2018 Coastal Storm Season, and the NYSDOH Healthcare Facility

Evacuation Center Manual.

Table 11: Protective Actions

Protective Action Potential Triggers Authorization

De

fen

d-i

n-P

lace

Defend-in-Place is the ability of a

facility to safely retain all residents

during an incident-related hazard

(e.g., flood, severe weather,

wildfire).

Unforeseen disaster impacts cause facility

to shelter residents in order to achieve

protection.

May be initiated by the Incident

Commander ONLY in the absence of

a mandatory evacuation order.

Does not required NYSDOH

approval.

Sh

elt

er-

in-P

lace

Shelter-in-Place is keeping a small

number of residents in their present

location when the risks of relocation

or evacuation exceed the risks of

remaining in current location.

Disaster forecast predicts low impact on

facility.

Facility is structurally sound to withstand

current conditions.

Interruptions to clinical services would

cause significant risk to resident health

and safety.

Can only be done for coastal storms.

Requires pre-approval from

NYSDOH prior to each hurricane

season and re-authorization at time

of the incident.



Protective Action Potential Triggers Authorization In

tern

al

Relo

ca

tio

n

Internal Relocation is the

movement of residents away from

threat within a facility.

Need to consolidate staffing resources.

Consolidation of mass care operations

(e.g., clinical services, dining).

Minor flooding.

Structural damage.

Internal emergency (e.g., fire).

Temperature presents life safety issue.

Determined by facility based on

safety factors.

If this protective action is selected,

the NYSDOH Regional Office must

be notified.

Ev

ac

ua

tio

n

Evacuation is the movement of

residents to an external location

(e.g., a receiving facility) due to

actual or anticipated unsafe

conditions.

Mandatory or advised order from

authorities.

Predicted hazard impact threatens facility

capacity to provide safe and secure

shelter conditions.

Structural damage.

Emergency and standby power systems

failure resulting in facility inability to

maintain suitable temperature.

Refer to the NYSDOH Evacuation

Plan Template.

Lo

ckd

ow

n

Lockdown is a temporary

sheltering technique used to limit

exposure of building occupants to

an imminent hazard or threat.

When ―locking down,‖ building

occupants will shelter inside a room

and prevent access from the

outside.

Presence of an active threat (e.g., active

shooter, bomb threat, suspicious

package).

Direction from law enforcement.

Determined by facility based on the

notification of an active threat on or

near the facility premises.



Annex B: Resource Management

1. Preparedness

Additionally, the facility maintains an inventory of emergency resources and corresponding

suppliers/vendors, for supplies that would be needed under all hazards, including:

Generators

Fuel for generators and vehicles

Propane tanks

Food and water for a minimum of 72 hours for staff and residents

Disposable dining supplies and food preparation equipment and supplies

Medical and over-the-counter pharmaceutical supplies

Personal protective equipment (PPE), as determined by the specific needs for each

hazard

Emergency lighting, cooling, heating, and communications equipment

Resident movement equipment (e.g., stair chairs, bed sleds, lifts)

Durable medical equipment (e.g., walkers, wheelchairs, oxygen, beds)

Linens, gowns, privacy plans

Housekeeping supplies, disinfectants, detergents

Resident specific supplies (e.g., identification, medical risk information, medical records,

physician orders, Medication Administration Records, Treatment Administration Records,

Contact Information Sheet, last 72 hours of labs, x-rays, nurses’ notes, psychiatric notes,

doctor’s progress notes, Activities of Daily Living (ADL) notes, most recent History and

Physical (H&P), clothing, footwear, and hygiene supplies)

Administrative supplies

The facility’s resource inventory will be updated annually to ensure that adequate resource levels

are maintained, and supplier/vendor contact information is current.

2. Resource Distribution and Replenishment

During an incident, the Incident Commander—or Logistics Section Chief, if activated—will release

emergency resources to support operations. The Incident Commander—or Operations Section

Chief, if activated—will ensure the provision of subsistence needs.

The Incident Commander—or Planning Section Chief, if activated—will track the status of

resources used during the incident. When defined resource replenishment thresholds are met,

the Planning Section Chief will coordinate with appropriate staff to replenish resources, including:



Procurement from alternate or nontraditional vendors

Procurement from communities outside the affected region

Resource substitution

Resource sharing arrangements with mutual aid partners

Request for external stockpile support from healthcare associations, local emergency

management.

3. Resource Sharing

In the event of a large-scale or regional emergency, the facility may need to share resources with

mutual aid partners or healthcare facilities in the community, contiguous geographic area, or

across a larger region of the state and contiguous states as indicated.

4. Emergency Staffing

4.1. Off-Duty Personnel

If off-duty personnel are needed to support incident operations, the facility will conduct the

following activities in accordance with facility-specific employee agreements:

Table 12: Off-Duty Personnel Mobilization Checklist

Off-Duty Personnel Mobilization Checklist

x The senior most on-site facility official will confirm that mobilization of off-duty

personnel is permissible (e.g., overtime pay).

X

Once approved, Department Managers will be notified of the need to mobilize off-duty personnel.

X

Off-duty personnel will be notified of the request and provided with instructions including:

Time and location to report Assigned duties Safety information Resources to support self-sufficiency (e.g., water, flashlight)

X Once mobilized, off-duty staff will report for duty as directed.

X

If staff are not needed immediately, staff will be requested to remain available by phone.



To mobilize additional off-duty staff, the facility may need to provide additional staff support services (e.g., childcare, respite care, pet care). These services help to incentivize staff to remain on site during the incident, but also need to be carefully managed (e.g., reduce liability, manage expectations).

4.2. Other Job Functions

In accordance with employment contracts, collective bargaining agreements, etc., an employee

may be called upon to aid with work outside of job-prescribed duties, work in departments or carry

out functions other than those normally assigned, and/or work hours in excess of (or different

from) their normal schedule. Unless temporarily permitted by an Executive Order issued by the

Governor under section 29-a of Executive Law, employees may not be asked to function out-of-

scope of certified or licensed job responsibilities.

The Incident Management Team will request periodic updates on staffing levels (available and

assigned). In addition to deploying clinical staff as needed for resident care activities, non-medical

assignments from the labor pool may include:

Security augmentation

Runners / messengers

Switchboard support

Clerical or ancillary support

Transportation

Resident information, monitoring, and one-on-ones, as needed

Preparing and/or serving meals, snacks, and hydration for residents, staff, visitors, and

volunteers

Cleaning and disinfecting areas, as needed

Laundry services

Recreational or entertainment activities

Providing information, escorts, assistance, or other services to relatives and visitors

Other tasks or assignments as needed within their skill set, training, and

licensure/certification.

In accordance with employment contracts, collective bargaining agreements, etc., and at the

determination of the Incident Commander, all or some staff members may be changed to 12-hour

emergency shifts to maximize staffing. These shifts may be scheduled as around regular work

hours, in six or 12-hour shifts, or as needed to meet facility emergency objectives.



4.3. Surge Staffing

If surge staffing is required—for example, staff has become overwhelmed—it may be necessary

to implement surge staffing (e.g., staffing agencies), and sharing of staff with our sister facility

Sprain Brook Manor in Scarsdale, NY

The facility may coordinate with pre-established credentialed volunteers included in the facility

roster or credentialed volunteers associated with programs such as Community Emergency

Response Team (CERT), Medical Reserve Corps (MRC), and ServNY.

The facility will utilize emergency staffing as needed and as identified and allowed under executive

orders issued during a given hazard/emergency.



Annex C: Emergency Power Systems

1. Capabilities

In the event of an electrical power disruption causing partial or complete loss of the facility’s

primary power source, the facility is responsible for providing alternate sources of energy for staff

and residents (e.g., generator).

In accordance with the facility’s plans, policies, and procedures,13 the facility will ensure provision

of the following subsistence needs through the activation, operation, and maintenance of

permanently attached onsite generators:

Maintain temperatures to protect resident health and safety and for the safe and sanitary

storage of provisions;

Emergency lighting;

Fire detection and extinguishing, and alarm systems; and

Sewage and waste disposal.

2. Resilience and Vulnerabilities

Onsite generators and associated equipment and supplies are located, installed, inspected,

tested, and maintained in accordance with the National Fire Protection Association’s (NFPA)

codes and standards.

In extreme circumstances, incident-related damages may limit generator and fuel source

accessibility, operability, or render them completely inoperable. In these instances, an urgent or

planned evacuation will be considered if a replacement generator cannot be obtained in a timely

manner.

13 CMS requires healthcare facilities to accommodate any additional electrical loads the facility determines to be necessary to meet all subsistence needs required by emergency preparedness plans, policies, and procedures. It is up to each facility to make emergency power system decisions based on its risk assessment and emergency plan.



Annex D: Training and Exercises

1. Training

To empower facility personnel and external stakeholders (e.g., emergency personnel) to

implement plans, policies, and procedures during an incident, the facility will conduct the following

training activities:

Table 13: Training


Conduct comprehensive orientation

to familiarize new staff members

with the CEMP, including PEP

specific plans, the facility layout, and

emergency resources.


Orientation held upon employment.

Incorporate into annual educational

update training schedule to ensure

that all staff are trained on the use of

the CEMP, including PEP specific

plans, and core preparedness

concepts.


Annually and as needed.

Maintain records of staff completion

of training.


Annually

Ensure that residents are aware

appropriately of the CEMP, including

PEP specific plans, including what to

expect of the facility before, during,

and after an incident.


Discussed during resident council meeting, signage in main lobby, PEP plan available for review.

Identify specific training

requirements for individuals serving

in Incident Management Team

positions.


Dir of Maintenance will review these roles with staff as needed



2. Exercises

To validate plans, policies, procedures, and trainings, the facility will conduct the following

exercise activities:

Table 14: Exercises


Conduct one operations-based exercise (e.g., full-scale or

functional exercise). 14


Annually

Conduct one discussion-based exercise (e.g., tabletop exercise).


Annually

3. Documentation

3.1. Participation Records

In alignment with industry best practices for emergency preparedness, the facility will maintain

documentation and evidence of course completion through sign in sheets with dates of in-

services/ drills/ disaster conducted.

3.2. After Action Reports

The facility will develop After Action Reports to document

lessons learned from tabletop and full-scale exercises and

real-world emergencies and to demonstrate that the facility has

incorporated any necessary improvements or corrective

actions.

After Action Reports will document what was supposed to

happen; what occurred; what went well; what the facility can do differently or improve upon; and

corrective action/improvement plan and associated timelines.

14 If a facility activates its CEMP due to a disaster, the facility is exempt from the operational exercise for the year ending November 15. A facility is only exempt if the event is fully documented, a post-incident after action review is conducted and documented, and the response strengths, areas for improvement, and corrective actions are documented and maintained for three (3) years. However, the secondary requirement for a tabletop exercise still applies.



Annex E: Infectious Disease/Pandemic

Emergency

The circumstances of infectious disease emergencies, including ones that rise to the level of a

pandemic, vary due to multiple factors, including type of biological agent, scale of exposure,

mode of transmission and intentionality. Infectious disease emergencies can include outbreaks,

epidemics and pandemics. The facility must plan effective strategies for responding to all types

of infectious diseases, including those that rise to the higher level of pandemic.

The following Infectious Disease/Pandemic Emergency Checklist outlines the hazard-specific

preparedness, response, and recovery activities the facility should plan for that are unique to an

incident involving infectious disease as well as those incidents that rise to the occasion of a

pandemic emergency. The facility should indicate for each checklist item, how they plan to

address that task.

The Local Health Department (LHD) of each New York State county, maintains prevention

agenda priorities compiled from community health assessments. The checklist items noted in

this Annex include the identified LHD priorities and focus areas. Nursing homes should use this

information in conjunction with an internal risk assessment to create their plan and to set

priorities, policies and procedures.

This checklist also includes all elements required for inclusion in the facility’s Pandemic

Emergency Plan (PEP), as specified within the new subsection 12 of Section 2803, Chapter 114

of the Laws of 2020, for infectious disease events that rise to the level of a pandemic.

To assure an effective, comprehensive and compliant plan, the facility should refer to

information in Annex K of the CEMP Toolkit, to fully understand elements in the checklist

including the detailed requirements for the PEP.

A summary of the key components of the PEP requirements for pandemic situations is as

follows:

o development of a Communication/ Notification Plan,

o development of protection plans against infection for staff, residents, and families,

including the maintenance of a 2-month (60 day) supply of infection control personal protective

equipment and supplies (including consideration of space for storage), and

o A plan for preserving a resident’s place in and/or being readmitted to a residential health

care facility or alternate care site if such resident is hospitalized, in accordance with all

applicable laws and regulations.



Finally, any appendices and documents, such as regulations, executive orders, guidance, lists,

contracts, etc. that the facility creates that pertain to the tasks in this Annex, and/or refers to in

this Annex, should be attached to the corresponding Annex K of the CEMP Toolkit rather than

attached here, so that this Annex remains a succinct plan of action.

Infectious Disease/Pandemic Emergency Checklist

Preparedness Tasks for all Infectious Disease Events

X

Required

Provide staff education on infectious diseases (e.g., reporting requirements (see Annex K of the CEMP toolkit), exposure risks, symptoms, prevention, and infection control, correct use of personal protective equipment, regulations, including 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); 42 CFR 483.15(e) and 42 CFR § 483.80), and Federal and State guidance/requirements. The facility will in-service staff annually and on an on-going basis on infection control/ infectious diseases. Staff will be updated on any current, new policies and/or changes in policies in regards to infection control/ infectious diseases such as covid-19.

X

Required

Develop/Review/Revise and Enforce existing infection prevention, control, and reporting policies. Facility will monitor existing practice of infection prevention, control, and reporting policies through surveillance.

X

Recommended

Conduct routine/ongoing, infectious disease surveillance that is adequate to identify background rates of infectious diseases and detect significant increases above those rates. This will allow for immediate identification when rates increase above these usual baseline levels.

X

Recommended

Develop/Review/Revise plan for staff testing/laboratory services as indicated in conjunction wit CMS, CDC and NYSDOH guidelines

X

Required

Review and assure that there is, adequate facility staff access to communicable disease reporting tools and other outbreak specific reporting requirements on the Health Commerce System (e.g., Nosocomial Outbreak Reporting Application (NORA), HERDS surveys. Facility will continue to report outbreaks on NORA and report on HERDS as required by DOH requirements and standards.

X

Required

Develop/Review/Revise internal policies and procedures, to stock up on medications, environmental cleaning agents, and personal protective equipment as necessary. (Include facility’s medical director, Director of Nursing, Infection Control Practitioner, safety officer, human resource director, local and state public health authorities, and others as appropriate in the process). Facility will ensure medications; Hand Hygiene; cleaning and sanitizing agents as well as PPE are available for the facility..

X

Recommended

Develop/Review/Revise administrative controls (e.g., visitor policies, employee absentee plans, staff wellness/symptoms monitoring, human resource issues for employee leave).



X

Required

Develop/Review/Revise environmental controls (e.g., areas for contaminated waste). Facility will ensure area for contaminated waste are maintained and monitored to prevent transmission of disease

X

Required

Develop/Review/Revise vendor supply plan for re-supply of food, water, medications, other supplies, and sanitizing agents. Facility will ensure that sufficient supply are available for usage such as food, water, medication and sanitary agents as needed.

X

Required

Develop/Review/Revise facility plan to ensure that residents are isolated/cohorted and or transferred based on their infection status in accordance with applicable NYSDOH and Centers for Disease Control and Prevention (CDC) guidance. Facility will ensure that residents are isolated/ cohorted in designated areas as specified by DOH & CDC guidelines.

X

Recommended

Develop plans for cohorting, including using of a part of a unit, dedicated floor, or wing in

the facility or a group of rooms at the end of the unit, and discontinuing any sharing of a

bathroom with residents outside the cohort.

X

Recommended Develop/Review/Revise a plan to ensure social distancing measures can be put into place where indicated. Daily rounds and QA observation will be done on each shift to ensure all transmission interventions are followed.

x Recommended

Develop/Review/Revise a plan to recover/return to normal operations when, and as specified by, State and CDC guidance at the time of each specific infectious disease or pandemic event e.g., regarding how, when, which activities /procedures /restrictions may be eliminated, restored and the timing of when those changes may be executed.

Additional Preparedness Planning Tasks for Pandemic Events

X

Required

In accordance with PEP requirements, Develop/Review/Revise a Pandemic Communication Plan that includes all required elements of the PEP. Facility will continue to develop, revise and review all areas identified by PEP. Some areas covered but not limited to are infectious disease events and pandemic events. Facility Medical Director/DNS/Infection Control Practitioner/ Administrator/ ADNS will be involved in the planning and revision of the program.

X

Required

In accordance with PEP requirements, Development/Review/Revise plans for protection of staff, residents and families against infection that includes all required elements of the PEP. Facility will continue to develop, revise and review all areas identified by PEP for residents, staff and families against infection. Some areas covered but not limited to are infectious disease events and pandemic events. Facility medical director/DNS/Infection control practitioner/ Administrator/ ADNS will be involved in the planning and revision of the program.



X

Required

Develop/Review/Revise vendor supply plan for re-supply of food, water, medications, other supplies, and sanitizing agents. Facility will ensure that sufficient supply are available for usage such as food, water, medication and sanitary agents as needed.

X

Required

Develop/Review/Revise facility plan to ensure that residents are isolated/cohorted and or transferred based on their infection status in accordance with applicable NYSDOH and Centers for Disease Control and Prevention (CDC) guidance. Facility will ensure that residents are isolated/ cohorted in designated areas as specified by DOH & CDC guidelines.

X

Recommended

Develop plans for cohorting, including using of a part of a unit, dedicated floor, or wing in

the facility or a group of rooms at the end of the unit, and discontinuing any sharing of a

bathroom with residents outside the cohort.

X

Recommended Develop/Review/Revise a plan to ensure social distancing measures can be put into place where indicated.

X

Recommended Develop/Review/Revise a plan to recover/return to normal operations when, and as specified by, State and CDC guidance at the time of each specific infectious disease or pandemic event e.g., regarding how, when, which activities /procedures /restrictions may be eliminated, restored and the timing of when those changes may be executed.

Additional Preparedness Planning Tasks for Pandemic Events

Required

In accordance with PEP requirements, Develop/Review/Revise a Pandemic Communication Plan that includes all required elements of the PEP. Facility will continue to develop, revise and review all areas identified by PEP. Some areas covered but not limited to are infectious disease events and pandemic events. Facility Medical Director/DNS/Infection Control Practitioner/ Administrator/ ADNS will be involved in the planning and revision of the program.

Required

In accordance with PEP requirements, Development/Review/Revise plans for protection of staff, residents and families against infection that includes all required elements of the PEP. Facility will continue to develop, revise and review all areas identified by PEP for residents, staff and families against infection. Some areas covered but not limited to are infectious disease events and pandemic events. Facility medical director/DNS/Infection control practitioner/ Administrator/ ADNS will be involved in the planning and revision of the program.

Response Tasks for all Infectious Disease Events:



Recommended

The facility will implement the following procedures to obtain and maintain current guidance, signage, advisories from the NYSDOH and the U.S. Centers for Disease Control and Prevention (CDC) on disease-specific response actions, e.g., including management of residents and staff suspected or confirmed to have disease. Facility will maintain signage for residents, staff and visitors and follow advisories from DOH & CDC in relation to management of residents and staff suspected or confirmed to have a disease.

X

Required

The facility will assure it meets all reporting requirements for suspected or confirmed

communicable diseases as mandated under the New York State Sanitary Code (10 NYCRR 2.10 Part 2), as well as by 10 NYCRR 415.19. (see Annex K of the CEMP toolkit. The facility will follow advisories from DOH & CDC in relation to management of residents and staff suspected or confirmed to have a disease.



for reporting requirements).

X

Required

The facility will assure it meets all reporting requirements of the Health Commerce System, e.g. HERDS survey reporting. The facility will continue to report on HERDS as required by DOH.

X

Recommended

The Infection Control Practitioner will clearly post signs for cough etiquette, hand washing, and other hygiene measures in high visibility areas. Consider providing hand sanitizer and face/nose masks, if practical.

X

Recommended

The facility will implement the following procedures to limit exposure between infected and

non-infected persons and consider segregation of ill persons, in accordance with any

applicable NYSDOH and CDC guidance, as well as with facility infection control and

prevention program policies. The facility will continue to cohort and use designated unit for anyone with suspected or confirmed case of infectious disease.

X

Recommended

The facility will implement the following procedures to ensure that as much as is possible, separate staffing is provided to care for each infection status cohort, including surge staffing strategies: the facility will continue to cohort staff caring for residents with infectious disease.

X

Recommended

The facility will conduct cleaning/decontamination in response to the infectious disease in accordance with any applicable NYSDOH, EPA and CDC guidance, as well as with facility policy for cleaning and disinfecting of isolation rooms.

X

Required

The facility will implement the following procedures to provide residents, relatives, and friends with education about the disease and the facility’s response strategy at a level appropriate to their interests and need for information. The facility will continue to provide residents and relatives with education about the disease and the facility response strategy through robo calls, resident council and signage.

X

Recommended

The facility will contact all staff, vendors, other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to residents. Same will be done via phone calls, emails as well as Postings on frot doors and all areas of entry

X

Required

Subject to any superseding New York State Executive Orders and/or NYSDOH guidance that may otherwise temporarily prohibit visitors, the facility will advise visitors to limit visits to reduce exposure risk to residents and staff.

If necessary, and in accordance with applicable New York State Executive Orders and/or NYSDOH guidance, the facility will implement the following procedures to close the facility to new admissions, limit visitors when there are confirmed cases in the community and/or to screen all permitted visitors for signs of infection: The facility will continue to follow guidelines for visitation and screening process as specified by DOH.

Additional Response Tasks for Pandemic Events:



X

Recommended

Ensure staff are using PPE properly (appropriate fit, don/doff, appropriate choice of PPE per procedures). Staff will continue to be educated on PPE and hand hygiene on an annual and on-going basis.



X

Required

In accordance with PEP requirements, the facility will follow the following procedures to post a copy of the facility’s PEP, in a form acceptable to the commissioner, on the facility’s public website, and make available immediately upon request: The facility will post a copy of the PEP on facility website by September 15th 2020 and will also make available within facility upon request.

X

Required

In accordance with PEP requirements, the facility will utilize the following methods to update authorized family members and guardians of infected residents (i.e., those infected with a pandemic-related infection) at least once per day and upon a change in a resident's condition: Facility will notify family members and guardians of infection within the facility via robocall daily on a regular basis and upon any changes.

X

Required

In accordance with PEP requirements, the facility will implement the following procedures/methods to ensure that all residents and authorized families and guardians are updated at least once a week on the number of pandemic-related infections and deaths at the facility, including residents with a pandemic-related infection who pass away for reasons other than such infection: The facility will continue to provide families and guardians with education about the disease and the facility response strategy through robocalls on a regular basis and upon any change in residents condition.

X

Required

In accordance with PEP requirements, the facility will implement the following mechanisms to provide all residents with no cost daily access to remote videoconference or equivalent communication methods with family members and guardians: The facility will continue to provide families and guardians with education about infectious disease and deaths through robocalls and via telephone on a regular basis. Facility will provide residents with ipads for electronic communication with family members in addition to the use of facility phones at any time.

X

Required

In accordance with PEP requirements, the facility will implement the following process/procedures to assure hospitalized residents will be admitted or readmitted to such residential health care facility or alternate care site after treatment, in accordance with all applicable laws and regulations, including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); and 42 CFR 483.15(e): Facility will maintain infection control for all readmitted residents within the facility.

X

Required

In accordance with PEP requirements, the facility will implement the following process to preserve a resident's place in a residential health care facility if such resident is hospitalized, in accordance with all applicable laws and regulations including but not limited to 18 NYCRR 505.9(d)(6) and 42 CFR 483.15(e): facility will preserve a residents place if hospitalized in accordance with all applicable laws and regul ations if bedhold is available.



X

Required

In accordance with PEP requirements, the facility will implement the following planned procedures to maintain or contract to have at least a two-month (60-day) supply of personal protective equipment or any superseding requirements under New York State Executive Orders and/or NYSDOH regulations governing PPE supply requirements executed during a specific disease outbreak or pandemic. As a minimum, all types of PPE found to be necessary in the COVID pandemic should be included in the 60-day stockpile. This includes, but is not limited to:

– N95 respirators – Face shield – Eye protection – Gowns/isolation gowns – Gloves – Masks

– Sanitizer and disinfectants (meeting EPA Guidance current at the time of the pandemic)

– Hand Sanitizers Facility will maintain or contract to have at least 60 day supply of PPE as specified by DOH,and notify DOH via HERDS if supplies cannot be met



Recovery for all Infectious Disease Events

X

Required

The facility will maintain review of, and implement procedures provided in NYSDOH and CDC recovery guidance that is issued at the time of each specific infectious disease or pandemic event, regarding how, when, which activities/procedures/restrictions may be eliminated, restored and the timing of when those changes may be executed.

X

Required

The facility will communicate any relevant activities regarding recovery/return to normal operations, with staff, families/guardians and other relevant stakeholders

Adira at Riverside Rehabilitation

Comprehensive Emergency Management Plan Template

Part III – Toolkit

2020

Adira at Riverside Rehabilitation 120 Odell Avenue, Yonkers, NY 10701 www.adirariverside.com

Introduction

This Toolkit Template is meant to supplement the Comprehensive Emergency Management Plan

(CEMP) Template to help facilities develop and implement their CEMP. Annex K has been

updated to include guidance and format to comply with the new requirements of Chapter 114 of

the Laws of 2020 for the development of a Pandemic Emergency Plan (PEP). This document

provides a compendium of resources to help empower staff engaged in facility preparedness,

response, and recovery operations. Templates and tools should be reviewed and updated on a

regular basis.

Refer to Part 1 – Instructions for additional information about completion of this template.

Table of Contents

1. FACILITY OVERVIEW 5

2. HAZARD VULNERABILITY ANALYSIS 7

2.1. HVA Tools 7

2.2. HVA Process 8

2.2.1. Convene Staff with Facility-Specific Knowledge 8

2.2.2. Identify Facility-Specific Hazards 8

2.2.3. Assess Hazards 9

3. ACTIVATION CHECKLIST 10

3.1. Command Center 11

4. INCIDENT MANAGEMENT TEAM POSITION CHECKLISTS 12

4.1. Incident Commander 12

4.2. Public Information Officer 13

4.3. Safety Officer 14

4.4. Operations Section Chief 15

4.5. Planning Section Chief 16

4.6. Logistics Section Chief 17

4.7. Finance/Administration Section Chief 18

5. DEMOBILIZATION CHECKLIST 19

6. STAKEHOLDER ENGAGEMENT 21

6.1. County Office of Emergency Management 21

6.2. Fire Department and Law Enforcement 22

6.3. Other Stakeholders 23

6.3.1. Corporate / Parent Organization 23

6.3.2. Community Stakeholders 23

7. COMMUNICATIONS PLAN 25

7.1. Objectives 25

7.2. Implementation 25

7.3. Pre-Scripted Messaging 27

7.3.1. Internal Pre-Scripted Messaging 27

7.3.2. External Pre-Scripted Messaging 29

7.4. Communicating with the Public 29

8. PROTECTIVE ACTION DECISION SUPPORT 31

9. AFTER ACTION REVIEW PROCESS 33

10. AFTER ACTION REPORT TEMPLATE 34

11. RESOURCE MANAGEMENT 35

11.1. Resource Considerations 35

12. GLOSSARY 37

HAZARD ANNEX A: ACTIVE THREAT 41

HAZARD ANNEX B: BLIZZARD/ICE STORM 43

HAZARD ANNEX C: COASTAL STORMS 44

HAZARD ANNEX D: DAM FAILURE 45

HAZARD ANNEX E: EARTHQUAKE 46

HAZARD ANNEX F: EXTREME COLD 48

HAZARD ANNEX G: EXTREME HEAT 50

HAZARD ANNEX H: FIRE 52

HAZARD ANNEX I: FLOOD 54

HAZARD ANNEX J: CBRNE 56

HAZARD ANNEX K: INFECTIOUS DISEASE 58

HAZARD ANNEX L: IT/COMMUNICATIONS FAILURE 63

HAZARD ANNEX M: LANDSLIDE 66

HAZARD ANNEX N: POWER OUTAGE 67

HAZARD ANNEX O: TORNADO 68

HAZARD ANNEX P: WILDFIRE 69

1. Facility Overview

The facility overview provides an immediate reference sheet about each facility (or individual

buildings within a facility’s campus) for use when communicating with external parties during an

emergency (e.g., law enforcement, fire department, emergency management officials).

Table 1: Facility Overview

LOCATION AND CONTACT INFORMATION

Name of Facility Adira at Riverside Rehabilitation

Address 120 Odell Avenue, Yonkers NY 10701

Cross Streets Nepperhan Avenue

Telephone 914-964-3333

Fax 914-964-4726

Email

Website www.adirariverside.com

CONSTRUCTION

Construction Type Type 1&2

Year Building Constructed 2000

Number of Floors (above/below grade) 4

Square Footage 52,000

CAPACITY AND STAFFING

Non-Traditional Surge Space Dining rooms,

Number of Facility-Owned Vehicles (including accessible spots/seats)1

0

UTILITY AND SERVICE PROVIDERS

Electric Provider Con Edison - 877-427-2255

Local Water Provider Consolidated Water Supply - 914-993-1538

Telephone Provider Compu Phone – 718-230-9292

Internet Service Provider OPTIMUM-1-866-218-1815

Generator Services PowerHouse – 917-855-2310

Propane NA

Plumbing Pagano Plumbing - 914-423-3700

Elevator ThyssenKrupp - 914-345-5361

HVAC Equipment ChutePlus - 516-300-3583

Fire Equipment/Sprinklers Allsafe fire sprinkler system Inc. 1-888-325-5723

1 This field is intended to capture number of vehicles, including accessibility level (e.g., number of wheelchair accessible spots, number of seats).

2. Hazard Vulnerability Analysis

2.1. HVA Tools

The Centers for Medicare and Medicaid Services (CMS) requires healthcare facilities to conduct

annual facility-specific risk assessments to identify and assess potential hazards and their

impacts. HVAs are used to estimate the hazards (and associated risks) that are most likely to

occur and/or may affect a facility’s ability to maintain operations and services. The results of the

analysis can be used to prioritize planning, mitigation, response, and recovery projects and

initiatives.

Below are example HVA tools that facilities can use to conduct a facility-specific HVA. Facilities

can modify the tools to suit their needs.

Table 2: Example HVA Tools

Tool Name Description

Kaiser Permanente

HVA Tool2

An excel spreadsheet with incorporated formulas which provide

the user with relative risk percentages and summary

information.

Children’s Hospital

Colorado, Community

Hazard Vulnerability

Assessment Tool

An excel spreadsheet with incorporated formulas which provide

the user with relative risk percentages and summary

information. The tool includes capabilities throughout the four

phases of emergency management (mitigation, preparedness,

response, recovery) as a factor in calculating risk.

U.S. Department of Health

and Human Services,

Healthcare and Public Health

Sector Threat/Hazard

Assessment Module

Automated Tool

An excel spreadsheet that guides facilities through the hazard

analysis process through a series of guided questions. After

completing all the questions, the tool provides a comprehensive

list of risks associated with each hazard.

2 The Kaiser Permanente HVA Tool (2017) is available at https://www.calhospitalprepare.org/sites/main/files/file-

attachments/kp_incident_log_hva_template.xlsb.

https://www.calhospitalprepare.org/sites/main/files/file-attachments/kp_incident_log_hva_template.xlsb



2.2. HVA Process

The following outlines the process and recommendations for conducting a facility-specific HVA:

2.2.1. Convene Staff with Facility-Specific Knowledge

Conducting an HVA requires an in-depth knowledge of facility preparedness and response

capabilities. In addition, understanding the capabilities of response partners is another important

piece of completing an HVA. As a result, staff possessing this knowledge should be involved in

the HVA process, including:

Facility Senior Leader

Lead Clinical Staff

Head of Administration/Finance

Communications Staff

Completing the HVA can be done by a single knowledgeable staff member or as a collaborative

process with multiple staff members. For example, multiple staff members can complete an

individual HVA, then they can be compared to validate each assessment and a consensus can

be reached using the variety of assessments.

2.2.2. Identify Facility-Specific Hazards

In order to complete an HVA, staff must know the hazards which might affect their facility. The list

of hazards can be developed through a variety of means, including:

Historical knowledge of hazards

Subjective predictions of hazards

Using predetermined hazards in HVA tools

Using local emergency plans to determine hazards (also known as a ―community-based

assessment‖). Examples of these plans, which can be obtained from your Local Office of

Emergency Management, include:

– Hazard Mitigation Plans

– Emergency Operations Plans

– Threat and Hazard Identification and Risk Assessment

2.2.3. Assess Hazards

The risk each hazard poses to the facility is determined through a variety of factors. The table

below presents each factor and the considerations to make when evaluating them.

Table 3: HVA Considerations

Hazard Factor Considerations

Probability

Current local and regional plans

Manufacturer/vendor statistics

Subjective evaluations or best estimate

Human Impact

Potential for staff, resident, or visitor injury or death

Emotional or psychological impact

Local cultural norms

Property Impact

Cost to replace

Cost to set up temporary replacement

Cost to repair

Time to recover

Business Impact

Business interruption

Staff unable to report to work

Violation of contractual agreements, regulatory standards

Interruption of critical supplies

Reputation and public image

Financial impact or burden

Preparedness

Status of current plans

Staff training completion status

Availability of alternate sources for critical resources

Internal Response

Emergency resource levels

Durability/longevity of resources (without replenishment)

Internal resources ability to withstand disasters

Availability of backup systems

External Response

Types of agreements with community agencies

Relationship with local and state agencies

Relationship with local healthcare facilities

Relationship with community volunteers

Vendor pre-incident response plans and contracts

3. Activation Checklist

Any incident large or small can warrant the activation of the CEMP and the processes contained

within. This checklist describes the activities that should take place whenever the CEMP is

activated and the position that is responsible. Additional facility specific processes can be added

into the checklist.

Table 3: Activation Checklist

Task Completed By

X

Upon notification of hazard or threat from staff, residents, or

visitors, activate the CEMP.

Administration/DNS

X

Activate the Communications Plan. Administration

X

Notify staff of CEMP activation and the hazard or threat through

the [facility-specific system (e.g., mass notification system,

switchboard operator, overhead paging system)].

Administration

X

Assess the potential or actual impact of the incident on residents,

staff, and the facility.

Administration

X

Direct Incident Management Team to convene at designated

Command Center location.

Administration

X

Based on the hazard and using the ―Notification by Hazard Type‖

table in the CEMP, conduct required notifications.

Administration/ Director of Maintenance

X

Set-up the facility’s Command Center. Refer to section below

checklist for more information.

Administration

X

Deliver briefing to Incident Management Team, and other staff as

appropriate, on the incident including:

Extent or impact of the problem (e.g., hazards, life safety

concerns)

Number of residents injured or affected

Status of resident care and ancillary services

Current and projected staffing levels

Status of facility plant, utilities, and environment of care.

Incident Commander

Task Completed By

X

Develop an Incident Action Plan to establish goals and objectives

to guide incident response throughout the next operational period.

Operational period duration will be determined by Incident

Commander (e.g., 12 hours, shift change).

Incident Commander

X

Prepare and distribute position-specific checklists for the Incident

Management Team to use during incident response.

Planning Section Chief

X

Establish a meeting schedule for Incident Management Team to

maintain situational awareness of incident and response

operations.

Planning Section Chief

X

Notify residents and their relatives or responsible parties of hazard

information and response actions.

Public Information

Officer

X

Task facility staff with completing additional tasks to meet

established response goals and objectives.

Incident Management

Team

X

Continue to collect information about incident and its current or

projected impacts and perform position duties as assigned.

Incident Management

Team

3.1. Command Center

The facility Command Center serves as the central location for the Incident Management Team to conduct the following activities:

Plan and execute emergency operations;

Exchange information (e.g., briefings, check-in meetings); and

Store incident-related documentation.

Prior to an incident, facilities should consider the following when identifying a primary and contingency location for the Command Center:

Located within the facility (e.g., not off-site);

Provide space for tables and chairs; and

Provide access to computers/internet and communications equipment (e.g., landline

telephones, cell phones).

After an incident, if the pre-identified locations are rendered unusable—or if incident conditions require the Command Center to be relocated—the facility can utilize nearby facilities, or if absolutely necessary, a vehicle to serve as an off-site, mobile Command Center.

4. Incident Management Team Position

Checklists

The following checklists outline the responsibilities of each Incident Management Team position.

They should be adapted as needed based on the internal policies and procedures of the facility.

4.1. Incident Commander

INCIDENT COMMANDER

X

Activate the CEMP and necessary Incident Management Team positions.

X

Analyze potential threats or hazards (e.g., weather forecast, law enforcement intelligence) and assess potential or impacts on residents, staff, and the facility.

X

Brief the Incident Management Team on the nature of the problem, immediate issues, and the initial plan of action.

X

Evaluate expected or actual facility damage and assign staff to conduct a thorough site assessment.

X

In accordance with local plans or procedures, notify emergency management, law enforcement, and fire officials of incident conditions for situational awareness and to relay critical needs.

X

Facilitate regular briefings to review the status of response operations. Request status reports from staff on resident health and safety.

X

Observe the Incident Management Team for signs of stress and exhaustion and provide rest periods.

X

Determine the appropriate protective action based on the presence of potential or actual hazards to resident safety and well-being.

X

Share regular updates with residents and staff to maintain situational updates.

X

Authorize procurement and distribution of resources.

4.2. Public Information Officer

PUBLIC INFORMATION OFFICER

X

Obtain briefing from Incident Commander.

X

Draft initial message for notification of relatives and responsible parties regarding facility and resident status.

X

Answer inquiries from residents’ relatives and responsible parties, the general public, and the media and direct questions/requests to appropriate individuals.

X

Develop and disseminate status updates to be reviewed and approved by the Incident Commander before dissemination to relatives and responsible parties, media, and the public.

X

Provide guidance to other Incident Management Team members on the appropriate release of information to requesting entities.

X

Develop regular status updates to keep staff informed of the incident and facility status.

X

Assist in the development and distribution of signage as needed.

X

Communicate concerns to the Incident Commander, as needed.

4.3. Safety Officer

SAFETY OFFICER

X


X

Conduct site assessment to determine safety risks of the incident to residents, staff, and visitors.

X

Document the treatment plan for injured or ill staff.

X

Post non-entry signs around unsafe areas.

X

Evaluate building or incident hazards and identify vulnerabilities.

X

Assess operations and practices of staff, terminate any unsafe activity, and recommend corrective actions to ensure safety of residents, staff, and visitors.

X

Direct laundry and housekeeping staff to:

Ensure adequate supplies of linens, blankets, and pillows.

Ensure emergency linens are available for soaking up spills and leaks.

X

Direct food and dietary staff to:

Provide and prepare food as needed during an emergency.

Ensure gas appliances are turned off before evacuating.

X

Submit resource requests to the Logistics Section Chief (if activated), as needed.

X


4.4. Operations Section Chief

OPERATIONS SECTION CHIEF

X Obtain briefing from Incident Commander.

X Assign staff to assess the facility and resident well-being.

X

Determine how facility services will continue as routinely as possible, including the provision of:

Routine nursing services and documentation

Medication dispersal per resident schedules.

Routine hygienic and nutritional care for residents.

X

Arrange for the provision of and/or documentation, transfer, and transportation critical medical services, such as dialysis and oxygen therapy, and emergency discharges for at- risk residents.

X Maintain resident and staff accountability.

X Secure resident records during shelter-in-place operations.

X

Assess pharmacy supplies and contact pharmacy, as needed, to determine:

Cancellation of deliveries.

Availability of backup pharmacy.

Availability of medical supplies.

X Evaluate staffing needs and activate additional staff, as needed.

X

Direct nursing and rehabilitation staff to:

Tend to physical and emotional needs of residents.

Assist in clearing rooms and hallways, exits, etc.

Support movement of residents during an evacuation.

X

For receiving facility operations, ensure proper management of arriving residents and their records, including documentation of triage, treatment, and disposition of emergency admits.

X Document resident injuries (and action plan to ensure treatment) or deaths.

X Submit resource requests to the Logistics Section Chief (if activated), as needed.

X Communicate concerns to the Incident Commander, as needed.

4.5. Planning Section Chief

PLANNING SECTION CHIEF

X


X

Document Incident Management Team position assignments and contact information for all positions.

X

Assist Incident Commander with planning response actions for next operational period (e.g., shift).

X

Ensure backup and protection of existing data including paper-based and digital systems.

X

Maintain all historical information and records related to the incident.

X


X


4.6. Logistics Section Chief

LOGISTICS SECTION CHIEF


Distribute resource request forms to each Incident Management Team member. Document the request, use, return, and condition of resources used to respond.

Ensure the following resources are mobilized, assigned, and tracked:

Staff and Surge Support

Emergency Supplies

Communications Equipment

Food and Water

Transportation

Document volunteer sign-in and sign-out for each operational period (e.g., shift).

Request Incident Commander approval to activate mutual aid and vendor agreements for additional resources.


4.7. Finance/Administration Section Chief

FINANCE/ADMINISTRATION SECTION CHIEF


Initiate protection of, or move/relocate facility records, as needed.

Maintain incident cost tracking and analysis, including the documentation, retrieval, safeguarding and distribution of cash, credit card, and receipt/invoice processes.

Document and track facility-wide personnel work hours worked relevant to the emergency.

Contact insurance company to notify them of the incident and identify and document requirements for submitting damage/claim reports.

Consult with government officials regarding reimbursement regulations, requirements, and forms.

Approve and submit a financial status report to the Incident Commander summarizing cost- to-date financial data relative to personnel, supplies, and miscellaneous expenses.

Ensure that required financial and administrative documentation is properly prepared and maintained.

Process invoices received.



5. Demobilization Checklist

Table 4: Demobilization Checklist

Tasks

Activate repatriation process.

Refer to the NYSDOH Evacuation Plan Template for further guidance.

Ensure compliance with all local and NYSDOH requirements regarding inspections, remediation actions, and conditions for approval of repatriation.

Receive approval from NYSDOH to reopen the facility.

Initiate repatriation plans and procedures.

Deactivate IMT positions and surge staffing.

Determine if there is an adequate number of facility personnel to meet remaining incident needs.

Deactivate IMT positions that are no longer needed.

Reduce surge staff (e.g., off-duty personnel, volunteers, contract support) and provide guidance on close-out procedures (e.g., where to submit documentation).

Return or restore emergency resources.

Estimate current and anticipated resource requirements.

Determine which facility-owned resources need to be returned to storage locations in the facility; or replenished/repaired for future incidents.

Determine processes for transitioning borrowed resources back to sending facility/provider.

Reactivate normal services and operations.

Determine when it is safe to resume normal operations after conferring with the local authority, NYSDOH Regional Office, fire department, law enforcement, public health, and/or any other response authority.

Compile documentation for recordkeeping purposes.

Collect and manage documentation related to: disaster-related expenses, property damage, direct operating costs, consequential loss, damaged or destroyed equipment, construction-related expenses.

Conduct debriefings with staff and volunteers.

Write an After-Action Report.

6. Stakeholder Engagement

This tool describes the relationships facilities should strive to build with local response partners

during pre-incident planning. Building a better relationship with these agencies will streamline

incident response and information sharing. Trying to construct these relationships will be

considerably more difficult during the middle of an incident.

6.1. County Office of Emergency Management

Forming a partnership with the County Office of Emergency Management is one of the more

important relationships a facility can build within the community. Emergency management

agencies are often the source of the most current and up to date information regarding incidents

and hazards.

Establishing a line of communication with the local office of emergency management will help

streamline critical information sharing and coordination with facilities. In addition, emergency

management agencies can provide opportunities to better prepare for incidents through

informational materials, trainings and exercises.

The following table outlines suggested action items for developing and maturing relationships with

emergency management agencies.

Table 5: Office of Emergency Management Engagement

Office of Emergency Management

Establish point of contact at the County Office of Emergency Management. (Note: A list of

county-specific agencies is available at http://www.dhses.ny.gov/oem/contact/map.cfm)

Clarify protocol and mechanisms for accessing information from the County Office of

Emergency Management, including:

Resource availability throughout the region

Pre-determined location list

Current available services and utilities

Hazard forecasts

Mass notification systems

Understand jurisdiction’s response processes and capabilities, including available

resources and response priorities in a large disaster.

Identify available opportunities for training and exercises with the County Office of

Emergency Management.

http://www.dhses.ny.gov/oem/contact/map.cfm

Office of Emergency Management

Identify critical information that the facility should relay to the County Office of Emergency

Management before and during a disaster (e.g., facility status, number of residents

needing transport, or infrastructure status).

Seek County Office of Emergency Management input on CEMP development.

6.2. Fire Department and Law Enforcement

Enhancing relationships with first responder agencies are also critical to expediting the response

process. These agencies will often be the first of the group to support facilities and relay critical

incident information.

The following table outlines suggested action items for maturing relationships with fire department

and law enforcement agencies.

Table 6: Fire Department and Law Enforcement Engagement

Fire Department and Law Enforcement

Establish point of contact at fire department, emergency medical services, and law

enforcement agency.

Identify what critical information should be relayed to fire department, emergency medical

services, and law enforcement agencies before, during, and after a disaster.

Identify opportunities for training and exercises with fire department and law enforcement

agencies.

Solicit fire department and law enforcement agency input on recommendations to expedite

response and recovery actions, including pre-staging equipment/resources, best ingress

and egress from facility, and debris removal to restore emergency access.

6.3. Other Stakeholders

6.3.1. Corporate / Parent Organization

If the facility is part of a larger multi-facility system, the facility should coordinate with its parent

organization to ensure pre- and post-incident activities adhere to corporate policies, and to ensure

the facility is appropriately empowered to execute incident management functions (e.g.,

permissions for external messaging, clarification of branding standards).

6.3.2. Community Stakeholders

Facilities are encouraged to build relationships with additional community stakeholders to assist

with the disaster response and recovery. Some examples of the assistance that can be provided

include volunteer support, surge staffing, and resources.

Community stakeholders may be different for every facility, but may include resource providers

and vendors (e.g., transportation providers, fuel); local subject matter experts (e.g., engineering,

finance and recovery, sustainability and mitigation); and volunteer resources.

The table below outlines potential volunteer resources that may be utilized to augment or

supplement facility staff and operations prior to, during, or after an emergency.

Table 7: Volunteer Resources

Entity Description and Skills

ServNY

Administered by the NYSDOH Office of Health Emergency Preparedness,

ServNY is an online registration system for licensed healthcare professionals to

volunteer when local and regional resources are exhausted. Volunteers are

notified of staffing requests via phone or email. ServNY may also be activated

by:

County Office of Emergency Management submits a request to the New

York State Office of Emergency Management, which sends the request to

Emergency Support Function-8 State Health Desk, and then to the

NYSDOH Emergency Preparedness; or

Direct order of the NYSDOH Commissioner or designee.

Entity Description and Skills

Community

Emergency

Response Team

(CERT)3

Community volunteers that are trained in disaster preparedness and basic

disaster response skills. These skills include:

Fire Suppression

Simple Triage and Rapid Treatment

— Airway obstruction

— Bleeding

— Shock

— Basic first aid

— Establishing a medical treatment area

Light Search and Rescue

Team Organization

Medical Reserve

Corps (MRC)4

MRC volunteers are imbedded in ServNY. Volunteers include practicing and

retired medical and public health professionals. MRC volunteers can support

response capabilities such as:

Disaster medical support

Health screenings

Vaccination clinics

Medical facility surge capacity

Planning, logistical, and administrative support

3 Facilities can locate their local CERT program at https://community.fema.gov/Register/Register_Search_Programs 4

Facilities can locate their local MRC program at https://mrc.hhs.gov/FindMRC

https://community.fema.gov/Register/Register_Search_Programs

https://mrc.hhs.gov/FindMRC

7. Communications Plan

A communications plan helps facilities maintain situational awareness throughout the duration of

an incident and enables facilities to share information effectively across the organization, as well

as with any external partners who may be supporting the response.

7.1. Objectives

Ensure communication policies, roles, and activities are clearly defined and well-understood

by staff.

Ensure internal and external communications are accurate, timely, and informative.

Provide frequent updates to residents, staff, relatives/responsible parties to mitigate

concerns and manage expectations.

Only share known/confirmed information (i.e., do not speculate).

Utilize one unified voice to avoid confusion or misinformation.

7.2. Implementation

Table 8: Communications Checklist

Communications Checklist

Preparedness

Designate and train personnel to serve as Public Information Officer prior to an incident (i.e.,

during normal operations). Potential training courses include:

FEMA IS-29: Public Information Officer Awareness (Free Online Course)

FEMA IS-42: Social Media in Emergency Management (Free Online Course)

Develop and refine pre-scripted messaging that can be tailored for incident use.

Determine primary and redundant forms of communication:

Primary forms include landline-dependent communications such as telephones and

cellphones.

Redundant forms are not dependent on functioning landline communication (e.g.,

include two-way radios, satellite radios).

Ensure multiple personnel have administrative access, training, and policies and procedures

to the facility’s website, social media accounts, and voicemail system.

https://emilms.fema.gov/IS29/index.htm

https://emilms.fema.gov/is0042/curriculum/1.html

Communications Checklist

Maintain up-to-date contact information for designated notification parties for all residents

(e.g., relatives/responsible parties).

Maintain up-to-date contact information for all staff.

Clarify approval processes for internal and external messaging content (e.g., peer review,

senior leader final approval).

Incident Response

Request an updated on the incident from the Incident Management Team:

What happened?

What is the status of residents and personnel?

When will the incident be resolved?

Inform internal audiences (e.g., personnel) about incident updates before informing external

audiences.

Provide office personnel (e.g., receptionist) with guidance on where to direct incoming

inquiries (e.g., media, personnel, relatives/responsible parties, vendors).

Maintain a log of incoming calls, including:

Name of caller

Name of publication or media source

Phone number

Email address

General nature of inquiry and any deadlines

Develop a press release (or official facility statement) to post on facility website and social

media pages.

Update the facility’s voicemail recording to provide alternative contact information if the facility

is evacuated and/or to field incoming inquiries.

7.3. Pre-Scripted Messaging

Depending on the situation, numerous forms of alerts and warnings may be required to reach

staff, residents, relatives and responsible parties, and the media.

It is vital to have several staff members who are solely responsible for fielding calls from residents’

relatives and responsible parties and who are familiar with pre-scripted messaging usage. Only

authorized spokespersons (e.g., Public Information Officer) should manage media and public

inquiries.

7.3.1. Internal Pre-Scripted Messaging

To facilitate timely and effective communications, the following pre-scripted messaging templates

have been developed for facilities to tailor for incident-specific messaging. During an incident, the

facility will manage or coordinate the development and dissemination of these messages.

Immediate Messaging

Please note that for incidents that pose an immediate threat to health or safety (e.g., active threat

or fire), messaging should be short and direct (i.e., ―Enter the nearest room and lock the door,‖ or

in the case of fire, ―Evacuate the area immediately‖).

CEMP Activation

The following message should be delivered to on-duty staff members who will assume Incident

Management Team positions:

Adira at Riverside is currently experiencing (Description of Conditions) caused by

[Incident Name]. Emergency operations have begun in order to manage the incident.

You are receiving this message because of your role on the Incident Management Team.

Please report to Administrator’s office immediately. Continue to monitor available

communications channels for updates. Refrain from sharing this message or subsequent

updates with the public.

For more information, contact Eric Fischbein, Administrator via phone at 718-964-7245

or by email at [email protected]

The following message should be delivered to off-duty staff members who will be needed to

support incident operations:

Adira at Riverside is currently experiencing (Description of Conditions) caused by

(Incident Name)]. Emergency operations have begun in order to manage the incident.

You are receiving this message because of the need to request additional support for

incident operations. Please report to administrator’s office at (Time). Continue to monitor

available communications channels for updates. Refrain from sharing this message or

subsequent updates with the public.

Please be prepared to bring [Resources to Support Self-Sufficiency] and [Include Incident-

Specific Safety Information].

For more information, contact Eric Fischbein, Administrator via phone at 718-964-7245

or by email at [email protected]

Pre-Scripted Messaging for Residents

Resident care personnel are responsible for informing their residents of the incident. It is important

to accommodate for the unique needs of each resident and provide messaging appropriate to

each resident’s level of understanding.

Adira at Riverside is currently experiencing [Description of Conditions] caused by

[Incident Name]. Please [Directions for residents (e.g., “ready yourself to evacuate”;

“remain in your room”; “convene in the cafeteria”)].

If you have any questions or need anything, please call Eric Fischbein, Administrator at

718-964-7245. We will provide more information as it becomes available. Your safety is

our top priority. Thank you for your patience.

Messaging to Staff about Evacuation to Receiving Facility


[Incident Name]. Emergency operations are being established to manage the incident.

The impacts of [Incident Name] are [Expected to cause or are causing] significant damage

to the following areas: [List of Impacted Areas]

For the health, safety, and well-being of residents, Adira at Riverside will be evacuating

residents to [Receiving Facility]. This facility is located at [Street Address].

Messaging to Residents about Evacuation to Receiving Facility

Please ready yourself for evacuation. Staff will prepare and assist you. We will be aiding

those with mobility issues. At the [Receiving Facility], you will receive food, water, shelter,

and support services. We are notifying your relatives and responsible parties of the

evacuation.

For more information, please call Eric Fischbein, Administrator @ 718-964-7245

7.3.2. External Pre-Scripted Messaging

Voicemail Recording Website/Social Media Message


[Incident Name]. Emergency operations have been initiated to manage the incident.

[Provide high level information on residents’ status]. We are taking extensive actions to

protect residents. [For your safety and that of others, please do not attempt to come to the

facility]. [In the event of evacuation, add] For resident safety and well-being, residents

are being evacuated to [Location].

For more information, please contact Eric Fischbein, Administrator @ 718-964-7245.

Tweets, limited to 280 characters, or other short messages can include:

Adira at Riverside is experiencing [Incident Name]. Responders are working to resolve

the incident. Resident safety is our top priority. Do not attempt to visit facility at this time.

For information and updates, please call 914-964-3333

Proactive Messaging to Relatives and Responsible Parties

When communicating with relatives and responsible parties it is important to provide high level

information on the status of residents. If it is known that certain residents have been injured, or

there are fatalities, stress the seriousness of the incident but do not release resident information

until the status of injured residents and fatalities can be confirmed and the incident is contained.

Hello. This is [Name and Position] from [Facility Name]. We are [Calling/Emailing] you to

inform you that Adira at Riverside is currently experiencing [Description of Conditions]

caused by [Incident Name].

Emergency operations have been initiated to manage the incident. [Provide high level

information on residents’ status]. We are doing as much as we can to protect residents.

We will provide information as it becomes available. [In the event of evacuation, add] For

resident safety and well-being, residents are being evacuated to [Location].

For more information, please contact Eric Fischbein, Administrator @ 718-964-7245

7.4. Communicating with the Public

The facility should notify media outlets of the incident as deemed necessary by the Incident

Commander. Only the Public Information Officer and authorized facility spokespersons should

communicate with the public.

Key principles of communicating with the media and public are:

Be knowledgeable. Know the facts before reporting out.

Be strategic in what information is shared.

Be credible. Do not try to distort facts to protect the facility. The facility will be held

responsible for any misinformation that is provided by the Public Information Officer.

Be accessible to inquiries; be transparent.

Be proactive. Control messaging that is released and do not let the media and public

distort messaging. Correct any rumors that arise.

Be flexible. Ensure the audience understands that the situation is unfolding, and

information will be shared as it is made available.

Be calm and collected.

Be sure to provide contact information where the media and public can direct inquiries.

8. Protective Action Decision Support

Facilities should use sound decision-making criteria when considering which protective action to

implement (e.g., evacuate, defend-in-place). The following questions can be used to arrive at a

decision.

Table 9: Protective Action Considerations

Protective Action Considerations

Information and Intelligence

Have local authorities issued protective action guidance?

Have adjacent counties/municipalities protective action guidance?

What is the status of traffic near the facility?

What is the acuity of the current resident population?

What is the status of receiving facilities?

What is the capacity of receiving facilities to receive residents?

Have send-receive arrangements been put in place and verified?

Anticipated Impacts

What are the anticipated impacts on the facility?

What is the forecasted external temperature for the next seven days?

What facility infrastructure might be affected?

Are there any anticipated life safety issues?

Resource Levels

What are staffing levels?

Have surge-staffing options been implemented?

What is the status of medical, pharmaceutical, and resident care supplies?

What is the status of food and water?

Protective Action Considerations

What is the status of generators and fuel levels?

What is the status of transportation resources?

Have any vendors/service provider agreements been activated?

What are staffing levels?

Have surge staffing options been implemented?

9. After-Action Review Process

Following every exercise or real-world incident, it is vital to capture best practices, lessons

learned, and areas for improvement in an After-Action Report (AAR). Plans, policies, and

procedures should be updated to incorporate and address the outcomes outlined in each report.

Table 10: After-Action Review Process

After-Action Review Process

Designate a staff member(s) to conduct the After-Action Review process and solicit

information for the AAR through:

Post-incident/exercise discussions and evaluations.

Surveys and feedback forms from the Incident Management Team, staff, residents,

responsible parties, and emergency supply vendors, and local emergency

management providers.

Describe the event, be it a real-world incident or an exercise. Include as much detail as

possible. Questions to consider:

When and where did the event occur? How long did the response last?

What was the nature and magnitude of the event? (For exercises, what is the

summary of exercise activities?)

How did the incident impact residents, services, and the facility/facilities?

Select the focus areas for the AAR based on areas needing improvement.

Under each focus area, describe areas for improvement. Questions to consider:

What gaps, barriers, or challenges emerged?

What resources were needed that were not available?

What disruptions to services occurred?

How well did personnel understand their roles and responsibilities?

Identify next steps for improving future responses. If possible, develop an improvement

plan outlining priority levels, responsible parties, and estimated timelines for

implementation. Provide additional training to cover areas of weakness.

10. After-Action Report Template

Table 11: After-Action Report Template

Event Event Date

[Incident/Exercise Name]

[Date]

Event Description

[Brief description of incident/exercise]

Strengths

[Placeholder] [Placeholder] [Placeholder]

Areas for Improvement

[Placeholder] [Placeholder] [Placeholder]

Improvement Plan

Issue/Area for Improvement

Corrective Action

Responsible Party

Start Date Completion

Date

11. Resource Management

11.1. Resource Considerations

Before a disaster occurs, it is important to have send-receive agreements in place; have lists of

vendors and service providers; and have all necessary information about site generator systems

on hand. This information is vital to the internal facility response, can help first responders, and

can set accountability. When determining which resources may be necessary for facility

preparedness, consult the considerations below:

Generators

What reporting processes are in place in the event that a generator fails inspection, is

not properly maintained, or fails a test?

What positions are routinely trained on the process of establishing emergency power to

the building?

– Who is responsible for performing this task?

What procedures are in place to troubleshoot generator system failures?

How long can emergency power be sustained before having to replenish fuel if tank is

full?

What systems, capabilities, and/or resources will be impacted if power is lost and

emergency power is unable to be secured (e.g., food, water, ventilation)?

Fuel

Is the emergency fuel source municipal fuel or local/on-site fuel?

What is the current onsite fuel storage capacity?

Potable Water

Where is potable water stored on site?

What potential barriers are there to reaching the potable water during an emergency?

Will potable water storage be safe from contamination by flood waters or severe storms?

Who manages the potable water storage?

Transportation

Which types of vehicles are immediately available to the facility?

Are facility-owned vehicles maintained?

Where can facility-owned vehicles access fuel?

How many and which staff can operate facility-owned vehicles?

Should additional staff be trained pre-disaster as alternatives?

– Where are copies of operator licenses kept?

Do staff have identification and primary and alternate routes if normal travel is restricted or roads are closed?

12. Glossary

Table 12: Glossary

Term Definition

Activation

To begin the process of mobilizing a response team, or to set in motion an emergency operations (response) or recovery plan, process, or procedure in response to incident or exercise.

Automatic Sprinkler

Ceiling sprinklers are located throughout the facility and are activated by heat, thereby setting off the water flow and the alarm.

Defend-in-Place

The ability of a facility to safely retain their residents in an incident-related situation (e.g., flood, severe weather, wildfire). This is also known as ―hunkering down‖ during an event.

Demobilization

The orderly, safe, and efficient return of an incident resource to its original location and status.

Evacuation

Organized, phased, and supervised dispersal or removal of people from dangerous or potentially dangerous areas, and their reception and care in safe areas.

Evacuation Holding Area

Temporary refuge for residents and staff during a facility evacuation, and if needed, point of embarkation for transport for longer-term evacuations.

Evacuee

A person removed or moving from areas threatened or struck by a disaster.

Fire Alarm

Loud ringing of bells, which may be activated by detectors, sprinklers, or manually, to alert residents and staff. When the bells sound, one of the systems has been activated and an emergency is occurring.

Fire Doors

These doors cut off a wing or a portion of a wing from adjoining areas to prevent drafts, which carry smoke, and retards the spread of fire.

Hazard Something that is potentially dangerous or harmful, often the root cause of an unwanted outcome.

Term Definition

Hazard Vulnerability Analysis

A systematic approach to identifying all hazards that may affect an organization and/or its community, assessing the risk (probability of hazard occurrence and the consequence for the organization) associated with each hazard and analyzing the findings to create a prioritized comparison of hazard vulnerabilities. The consequence, or ―vulnerability,‖ is related to both the impact on organizational function and the likely service demands created by the hazard impact.

Incident Action Plan

An oral or written plan, containing objectives that reflect the overall strategy for managing an incident. It may include the identification of operational resources and assignments. It may also include attachments that provide direction and important information for management of the incident during one or more operational periods.

Incident Command System

A standardized on‐ scene emergency management construct specifically designed to provide for the adoption of an integrated organizational structure that reflects the complexity and demands of single or multiple incidents, without being hindered by jurisdictional boundaries. ICS is the combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure, designed to aid in the management of resources during incidents. It is used for all kinds of emergencies and is applicable to small as well as large and complex incidents. ICS is used by various jurisdictions and functional agencies, both public and private, to organize field‐level incident management operations.

Incident Management

The broad spectrum of activities and organizations providing effective and efficient operations, coordination, and support applied at all levels of government, utilizing both governmental and nongovernmental resources to plan for, respond to, and recover from an incident, regardless of cause, size, or complexity.

Incident Management Team

The Incident Management Team is comprised of pre-designated personnel who are assigned to plan and execute response and recovery operations. Incident Management Team activation is designed to be flexible and scalable depending on the type, scope, and complexity of the incident. As a result, the Incident Commander may decide to activate the entire team or select positions, based on the extent of the emergency.

Lockdown

A security measure taken during an emergency to prevent people from leaving a facility, and to prevent an active threat (one or more persons) from entering a facility.

Term Definition

Mitigation

Activities providing a critical foundation in the effort to reduce the loss of life and property from natural and/or manmade disasters by avoiding or lessening the impact of a disaster and providing value to the public by creating safer communities. Mitigation seeks to fix the cycle of disaster damage, reconstruction, and repeated damage. These activities or actions, in most cases, will have a long-term sustained effect.

Operational Period

The time scheduled for executing a given set of operation actions, as specified in the Incident Action Plan. Operational periods can be of various lengths, although usually they last 12-24 hours.

Preparedness

A continuous cycle of planning, organizing, training, equipping, exercising, evaluating, and taking corrective action in an effort to ensure effective coordination during incident response. Preparedness focuses on the following elements: planning; procedures and protocols; training and exercises; personnel qualification and certification; and equipment certification.

Receiving Facility

A facility that has entered into agreement with another facility (nursing home, adult care facility, hospital, etc.), offering to host residents and staff for some part of an emergency response.

Response

Activities that address the short‐term, direct effects of an incident. Response includes immediate actions to save lives, protect property, and meet basic human needs. Response also includes the execution of emergency operations plans and of mitigation activities designed to limit the loss of life, personal injury, property damage, and other unfavorable outcomes.

Recovery

The development, coordination, and execution of service- and site- restoration plans; the reconstitution of government operations and services; individual, private-sector, non-governmental, and public assistance programs to provide housing and to promote restoration; long-term care and treatment of affected persons; additional measures for social, political, environmental, and economic restoration; evaluation of the incident to identify lessons learned; post incident reporting; and development of initiatives to mitigate the effects of future incidents.

Secure Area

An area that has been checked and verified to be clear of fire/danger, with windows and doors closed, equipment shut down, and hallways free of obstacles.

Term Definition

Shelter-in-Place

NYSDOH defines shelter-in-place as the protective action strategy of keeping a small number of residents in their present location when the risks of relocation or evacuation exceed the risks of remaining in current location.

Can only be done for coastal storms. Requires pre-approval from NYSDOH prior to each hurricane season and pre-authorization at the time of the incident.

Please refer to the 2019 Evacuation Plan.

Situational Awareness

Is the ability to identify, process, and comprehend the essential information about an incident to inform the decision-making process in a continuous and timely cycle and includes the ability to interpret and act upon this information.

Smoke Detector

Smoke detectors are located on ceilings throughout the facility and respond to smoke thereby setting off the alarm.

Threat

Natural or manmade occurrence, individual, entity, or action that has or indicates the potential to harm life, information, operations, the environment, and/or property.

An active threat is an individual or group of individuals actively engaged in killing or

attempting to kill people in a confined and populated area, often through the use of firearms.

For all Hazard Annexes below the NYSDOH Regional Office is to be notified during normal

business hours. For events that occur on nights, weekends or holidays, notify the NYSDOH

Duty Officer at 866-881-2809.

Hazard Annex A: Active Threat

Preparedness

Conduct a walk-through of the facility to determine vulnerabilities (e.g., publicly accessible entrances), identify emergency escape routes, and determine necessary security measures (e.g., additional locks, cameras).

Train staff on security-related responsibilities and empower staff to report unusual, dangerous, or suspicious activity.

Train staff on the ―Run, Hide, Fight‖ options to enable staff to quickly act during a real- world situation.5

Create and implement policies for access control and security:

Require all persons to display an authorized identification badge or pass.

Ensure locked doors remain closed and locked.

Control dissemination of keys and/or keypad code access.

Identify emergency escape routes for each facility office, which may or may not be the

same as normal fire evacuation routes.

Identify outside gathering areas within a half mile of the facility and communicate

location to staff members for staff, residents, and visitors to convene during an active

threat, as appropriate.

Conduct drills with law enforcement officials to familiarize first responders with the

facility (e.g., entrances/exits, building layout, notification procedures).

5 For more information, refer to Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans at http://www.phe.gov/Preparedness/planning/Documents/active-shooter-planning-eop2014.pdf

http://www.phe.gov/Preparedness/planning/Documents/active-shooter-planning-eop2014.pdf

Response

In response to an active threat, each individual (staff, residents, and visitors) will

determine the most appropriate response based on their proximity to the threat and

their mobility level.

RUN: If it is safe to do so, staff and residents should move as far away from the

threat as possible until they are in a safe location.

HIDE: If running is not a safe option—or for residents with mobility options—

individuals should hide in as safe a place as possible (e.g., thicker walls, fewer

windows, lock or barricade doors).

FIGHT: If neither running nor hiding is a safe option, as a last resort and when

confronted by the assailant, individuals in immediate danger should consider trying

to disrupt or incapacitate the assailant by using aggressive force and items in their

environment, such as fire extinguishers, chairs, etc.

The Regional Office or Watch Center should not be contacted as the event is in

progress. All DOH or Watch Center notifications should be done after law enforcement

has deemed the situation safe.

The facility will call 9-1-1 if there is a suspected or actual threat to the facility, staff, or

residents and will provide as much of the following information as possible:

Facility name and address;

Location and number of attacker(s);

Description of attacker(s), gender, clothing, among other points;

Number and location of any victims.

Type(s) of weapons if known.

After notifying authorities of the emergency, the facility will use its notification methods

to warn visitors, off-site staff, and others.

The facility will notify residents, visitors, and staff when law enforcement has determined

that the threat has been neutralized.

A blizzard has a wind speed of 35 mph or higher with blowing snow and extremely limited

visibility. An ice storm also reduces visibility and can immobilize ground and air

transportation leaving a facility isolated. Ice storms include freezing rain and sleet, both of

which cause sheets of ice to form on the ground, which can cause falls. Ice may also build

on tree limbs, wires, and awnings. Blizzards and ice storms can cause extreme cold and

power outages, and impede travel to and from the facility, impacting delivery of vital services

and supplies.

Hazard Annex B: Blizzard/Ice Storm

Preparedness

Procure sufficient rock salt/snow melt to clear primary passageways.

Monitor weather forecasts via radio and television (e.g., National Weather Service).

Begin preparations for a blizzard/ice storm as soon as a watch (storm is 36 – 48 hours out) or warning (storm is occurring or will occur in 24 hours) is issued.

Response

Ensure all staff and residents remain inside the facility.

Determine which staff will remain on site for up to 72 hours, as shift changes will not be

possible during a blizzard due to blocked roads. Develop and disseminate a schedule to

ensure all staff have breaks to rest, eat, and sleep.

If the heating system fails, prepare to evacuate, if possible. Contact the NYSDOH

Regional Office for guidance on whether to evacuate. If the decision is made to

evacuate, please refer to the NYSDOH Evacuation Plan Template.

Coastal storms may arrive as tropical depressions (maximum sustained winds of 38 mph or

less), tropical storms (maximum sustained winds of 39-73 mph), or hurricanes (maximum

sustained winds of 74 mph or more, ranging from Category 1-5). Hazards associated with

coastal storms include: flooding; flying debris; extreme winds and tornados; torrential rain;

and power outages due to downed trees and power lines.

Hazard Annex C: Coastal Storms

Preparedness

Determine which buildings, infrastructure, and essential services would be at risk by flooding.

Assess potential infrastructure impacts from winds and heavy rains:

Assess the ability of facility infrastructure to withstand extreme winds and rain.

Consider infrastructure-hardening measures (e.g., impact-resistant windows).

In the days prior to landfall, review forecast information and intelligence, anticipated impacts, and facility resource levels to determine facility readiness to implement protective actions.

Maintain communication with the County Office of Emergency Management and Health Emergency Preparedness Coalition to receive storm reports for the area.

In the absence of direction from NYSDOH and local authorities (e.g., mandatory evacuation order), determine which protective action to implement.

Implement protective action. Refer to Annex A: Protective Actions in the Base Plan for more information. If the decision is made to evacuate, please refer to the NYSDOH Evacuation Plan Template.

Reassess the situation at regular intervals (e.g., 96 hours, 72 hours, 48 hours, 24 hours) to determine whether additional protective actions are required.

Response

Evaluate conditions of staff and residents and identify needs and gaps in services.

Assess infrastructure damage and continued threats to staff and residents.

Report status to external partners (e.g., NYSDOH Regional Office, County Office of

Emergency Management) and/or relatives and responsible parties, as appropriate.

The response to a dam failure will depend on the amount of warning time, which will depend

on the cause and extent of flooding or primary dam failure. Heavy rains downstream may

give a facility time to prepare for a dam failure while intense storms with flash flooding could

cause failure within minutes. It is important to respond immediately to any kind of siren/alarm

and/or warning coming from dam officials.

Hazard Annex D: Dam Failure

Preparedness

Identify dams near the facility.

Work with County Office of Emergency Management officials to identify the best preparedness actions specific to nearby dams.

Identify which facility buildings, infrastructure, and essential services would be in the path of flood waters as the result of a dam failure.

Consider mitigation activities in areas susceptible to water intrusion.

Develop procedures for relocating resources, vital records, and equipment to assure continuation of services and to prevent damage or loss.

Response

If the facility suffers structural damage or if supporting utilities are compromised (e.g., power, water), consider the implementation of a protective action. Refer to Annex A: Protective Actions in the Base Plan for more information.

Regularly seek updates on both staff and resident well-being to determine if other protective actions are needed for some or all of the facility’s population.

Consider all flood water contaminated. Avoid walking through floodwater and wash hands thoroughly after contact. Do not use pre‐packaged food and drink products that

have come into contact with floodwater.

Gather critical supplies to take to higher ground (e.g., medications, drinking water, health records, important personal items, communication devices, blankets).

Do not allow electrical devices to come into contact with water.

If the decision is made to evacuate, please refer to the NYSDOH Evacuation Plan Template.

Earthquakes cannot be predicted and are considered “no-notice” incidents. Hazards

associated with earthquakes include: tsunami (flooding); power outages; fires, and

landslides.

Hazard Annex E: Earthquake

Preparedness

Ensure structures are in full compliance with regional building codes.

Implement earthquake protection measures for utilities:

Repair defective electrical wiring.

Repair leaky gas lines.

Install automatic shut off valves triggered by strong vibrations.

Repair or replace inflexible utility connections and fittings.

Protect staff and residents from movable objects:

Secure water heaters, refrigerators, furnaces and/or boilers, washing machines and

dryers, and other gas appliances.

Secure top-heavy items.

Store large or heavy items on lower shelves.

Secure cabinets.

Secure overhead lighting.

Stage multiple small fire extinguishers throughout the facility and provide training on fire extinguisher use and associated hazards.6

Response

During Earthquake

Do not attempt to leave the building during an earthquake.

Instruct residents in wheelchairs to lock their wheels in a safe position and cover their head and neck with their arms if they are able to.

6 29 Code of Federal Regulations, 1910.157(g)(1) states that ―Where the employer has provided portable fire extinguishers for employee use in the workplace, the employer shall also provide an educational program to familiarize employees with the general principles of fire extinguisher use and the hazards involved with incipient stage fire-fighting.‖ Paragraph (g)(2) states that the ―education‖ required in paragraph (g)(1) ―must be provided to employees upon initial employment and at least annually thereafter.‖

Instruct residents in beds to remain in their beds.

Instruct personnel to take cover under a desk, table, in a doorway. Place hands over your head for protection. Stay away from windows, glass, and exterior doors.

Encourage everyone to remain in place for a few minutes after the initial shock as aftershocks may occur.

After Earthquake

Survey the facility for injuries, structural damage, fire, ruptured gas or water pipes, etc. If necessary, shut off utility lines and/or panels.

Assign staff to assess residents for any injuries that require immediate attention.

Assess the facility for damage that requires immediate attention (e.g., gas leaks, fires, broken glass, spills).

If there is a fire, follow facility protocol.

If a gas leak is suspected, notify the Plant Manager.

If electrical system damage is suspected, follow facility protocol.

If sewage and water line damage is identified, follow facility protocol.

Comply with public health notices/orders regarding water contamination and utilize emergency potable water resources.

If the facility has suffered structural damage, or if supporting utilities are compromised (e.g., power, water), consider the implementation of a protective action. Refer to Annex A: Protective Actions in the Base Plan for more information.


Seek updates from staff on both staff and resident well-being to determine if other protective actions are needed for some or all of the facility’s population.

Extreme cold can occur independent of any snow, ice, or storm systems. Extreme cold

events involve an extended period with temperatures at or below 32°F. The risk to health and

personal safety during extreme cold is exacerbated by utility service interruption or loss.

Therefore, the facility maintains its building systems ahead of any extreme weather

projections. The facility acknowledges and prepares for the possibility of short staffing due

to road conditions.

Hazard Annex F: Extreme Cold

Preparedness

Conduct regular building maintenance and inspection, including maintenance of heating

and air conditioning systems and thermostats.

Test all generators involved in supplying power to areas for resident care and ensure

the facility has sufficient fuel on-site to fuel the generator for the period of extreme cold.

Routinely monitor the indoor facility temperature when the outdoor temperature is below

65 degrees Fahrenheit to ensure the indoor temperature in residents’ rooms and all

common areas is maintained at a minimum of 75 degrees Fahrenheit.7

Develop resident assessment protocol, including vital sign checks focusing on core

temperature and comfort checks.

Develop procedures for internal relocation of residents to warmer parts of the facility.

Document vendors for additional heating units. Establish agreements and/or contracts with vendors, as possible.

7

10 NYCRR 415.5 and 42 CFR 483.15 The regulations contained in 10NYCRR Part 713 require nursing homes to be equipped with

a heating system capable of maintaining all resident areas at a minimum temperature of 75 degrees Fahrenheit.

Response

Conserve heat:

Avoiding unnecessary opening of doors/windows

Close off unoccupied rooms

Cover windows

If the facility experiences heating equipment malfunctions during normal business

hours, immediately contact heating equipment service provider and notify the NYSDOH

Regional Office. For malfunctions that occur on nights, weekends or holidays, notify the

New York State Watch Center (Warning Point) at 518-292-2200.

If heating equipment has failed, regularly monitor individual room temperatures.

Initiate actions to safely increase resident comfort (e.g., provide additional blankets to

residents); offer warm liquids (keeping in mind relevant dietary

modifications/restrictions).

Assess residents for signs of distress and/or discomfort.

If the internal temperature of the facility remains low and potentially jeopardizes the

safety and health of residents, consider internal relocation to a warmer part of the

facility (on sunny side; downwind) or evacuation.

If the decision is made to evacuate, refer to the NYSDOH Evacuation Plan Template.

Extreme heat events are defined as periods when the heat index is 100°F or higher for one

or more days, or when the heat index is 95°F or higher for two or more consecutive days.

Prolonged periods of this heat accompanied by high humidity create a dangerous situation

for vulnerable populations. Elderly residents and those with chronic medical conditions

such as cardiopulmonary conditions, high blood pressure and residents with mental illness

are at increased risk for heat exhaustion, heat stroke and heat cramps.

Hazard Annex G: Extreme Heat

Preparedness

Regularly inspect the building’s HVAC system.

Maintain cooling supplies:

Portable fans and temporary cooling devices

Non-perishable foods and fluids

Develop procedures to monitor the physical environment of the facility (e.g.,

temperature, humidity, sun screening,ventilation).

Develop procedures for relocation to cooling centers inside the facility. Procedures for the internal relocation of residents to air-conditioned, or cooler areas, of the facility.

Educate staff on risks of extreme heat, including: heat cramp, heat exhaustion, heat

stroke, sunburn, and dehydration.

Develop resident assessment protocol, including vital sign checks focusing on core temperature, comfort checks, and checking for resident dehydration.

Response

Conduct wellness checks and safety precautions:

Check rooms regularly to ensure that air‐conditioning is operational.

Keep drapes and windows closed.

Decrease physical activity for residents.

Keep residents inside facility.

Monitor resident exposure and reactions to heat. Follow protocol for transfer to hospital if resident appears to be suffering from heat-related illness such as heat cramps, heat exhaustion, or heat stroke.

Consider re-locating residents to the coolest locations in the facility or creating ―cooling

centers‖ where residents can congregate with limited air conditioning, cool cloths, cold

beverages, and similar measures.

If the internal temperature of the facility remains high and potentially jeopardizes the

safety and health of residents, notify the NYSDOH Regional Office. On nights,

weekends or holidays, notify the New York State Watch Center (Warning Point) at 518-

292-2200.

If the decision is made to evacuate, please refer to the NYSDOH Evacuation Plan

Template.

Encourage residents to drink fluids to maintain hydration.

Fires may occur within the facility or may be a result of external fire activity, including

wildfires.

Hazard Annex H: Fire

Preparedness

Identify fire and life safety hazards inside the facility:

Missing or broken fire safety equipment

Blocked fire doors and evacuation routes

Accumulated trash

Burned out exit lights

Plant Manager will document and inspect facility’s fire and life safety emergency

systems, including:

Manual pull alarms

Smoke detectors

Exit doors and stairwells

Sprinklers System

Fire extinguishers

Fire alarm monitoring service

Self-closing fire doors

Test the facility’s fire alarm system and record outcomes, as required by NYSDOH

regulation.

Train all staff on the type of fire extinguishers in the building, their location, how to

access them, and the types of fires they should be used on.

Conduct quarterly fire drills at unexpected times, under varying conditions, and on each

shift.

Response

If the fire alarm system is out of service for more than four hours in a 24-hour period,

notify the Authority Having Jurisdiction, evacuate the building, or if approved, implement

a fire watch until the fire alarm system has been returned to service.

Rescue those in immediate danger in accordance with the facility’s fire rescue

Procedures.

Pull the fire alarm and then alert residents and staff members.

Contain the fire if possible.

Shut off air flow, as much as possible.

Close all fire doors and shut off fans, ventilation systems, and air

conditioning/heating systems.

Use available fire extinguishers if the fire is small and this can be done safely.

Relocate oxygen-dependent residents away from fire since oxygen supply lines

(whether portable or central) may lead to combustion in the presence of sparks or fire. If

necessary, remove oxygen and reconnect one resident is in a safe area.

If the decision is made to evacuate, please refer to the NYSDOH Evacuation Plan

Template.

Floods may be the result of coastal, lake, river, inland, or indoor flooding.

Hazard Annex I: Flood

Preparedness

Implement indoor flooding protection measures for buildings:

Repair and replace leaky or broken pipes.

Perform maintenance inspections on water heaters and washing machines.

Identify clogged sewer or drain lines and contact plumbing services, as needed.

Determine which buildings, infrastructure, and essential services may be at risk of flooding.

Consider mitigating risks associated with flooding:

Elevate the furnace, water heater, emergency generator, and electrical panel if

susceptible to flooding.

Install sewer backwater valves to prevent sewer backups.

Build barriers to prevent floodwater from entering the facility.

Utilize waterproofing materials to seal walls in basements or identified rooms.

Response

Maintain contact and communication with the County Office of Emergency Management

and Health Emergency Preparedness Coalition to receive flooding reports for the area.

If the facility has suffered structural damage, or if supporting utilities are compromised (e.g., power, water), consider the implementation of a protective action. Refer to Annex A: Protective Actions in the Base Plan for more information.


If the decision is made to internally relocate, gather critical supplies to take to higher ground (e.g., medications, drinking water, resident records, important personal items, communication devices, blankets).

Regularly seek updates from staff to determine if other protective actions are needed for some or all of the facility’s population.

Unplug non‐essential appliances, equipment, and computers. Do not allow electrical

devices to come into contact with water.

If a gas leak is suspected, notify the Plant Manager.

Check for water line ruptures and sewage contamination and report utility problems to the utility company.

If water lines are disrupted, consider the water supply to be contaminated and utilize the facility’s emergency potable water resources.

Comply with public health notices regarding water contamination (e.g., Boil Water, Do Not Drink Water, Do Not Use Water).

Consider all flood water contaminated. Avoid walking through floodwater and wash hands thoroughly after contact. Do not use pre‐packaged food and drink products that

have come into contact with floodwater.

CBRNE incidents occur when a hazardous substance is released into the environment,

causing potential harm to the staff and residents of the facility. CBRNE emergencies are

particularly dangerous for facilities, as populations are typically confined indoors with

compromised health and immune systems. Released toxic substances, even in small

amounts, can further weaken the health and well-being of residents.

Hazard Annex J: Chemical, Biological,

Radiological, Nuclear, Explosive

(CBRNE)

Preparedness

Determine the facility’s proximity to potential sources of CBRNE exposure (e.g.,

transportation corridors, nuclear power plant).

Work with local emergency management, public health, environmental health, and

other identified stakeholders to develop a decontamination plan.

Properly dispose of potentially toxic substances like unused chemicals,

pharmaceuticals, and other substances.

Conduct trainings on safe handling, transportation, and disposal of hazardous wastes.

Response

Maintain contact and communication with the County Office of Emergency Management

and Health Emergency Preparedness Coalitions to receive updated CBRNE threat

information for the area.

Based on the type and location of incident, assess potential impacts of a hazardous

materials release.

Review threat information and intelligence, anticipated impacts, and resource levels to

determine facility readiness to implement protective actions. Refer to Annex A:

Protective Actions in the Base Plan for more information.

If the decision is made to evacuate, refer to the NYSDOH Evacuation Plan Template.

Assess the need to set up ―hot, warm, and cold‖ zones for which access would be

restricted. Secure zones accordingly.

Provide guidance and implement protective measures for food handling, mass feeding,

and sanitation.

Preemptive methods to mitigate exposure to hazardous substance outside the facility:

Close all windows, doors, and vents.

Limit the amount of foot traffic in and out of the facility.

Do not allow residents outside, as possible.

If using heating or air conditioning, set to re-circulate indoor air to shut down

exterior air intake.

Carry out established decontamination procedures, as needed.

Monitor staff and residents for delayed physical responses as a direct result of the

incident.

Assess residents for worsened health outcomes as an indirect result of the incident.

Hazard Annex K: Infectious Disease

Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses,

parasites or fungi. The circumstances of infectious disease emergencies, including ones that

rise to the level of a pandemic, vary by multiple factors, including type of biological agent,

scale of exposure, mode of transmission and intentionality.

The facility follows effective strategies for preventing infectious diseases. Each county Local

Health Department-(LHD) has prevention agenda priorities compiled from community health

assessments that can be reviewed and utilized by the facility in fully developing your CEMP

Annex E, planning and response checklist for infectious disease and pandemic situations.

The information within this Annex includes the identified priorities and focus areas.

Under the Pandemic Emergency Plan (PEP) requirements of Chapter 114 of the Laws of

2020, special focus is required for pandemics. Please use the template’s Appendix E and

this Hazard Annex, with prompts for the PEP requirements, to ensure that the plans

developed meet all requirements.

Chapter 114 of the Laws of 2020 (full text):

Section 2803 of the public health law is amended by adding a new subdivision 12 to read as

follows:

12. (a) each residential health care facility shall, no later than Ninety days after the effective

date of this subdivision and annually thereafter, or more frequently as may be directed by the

commissioner, prepare and make available to the public on the facility's website, and

immediately upon request, in a form acceptable to the commissioner, a pandemic emergency

plan which shall include but not be limited to:

(i) a communication plan:

(a) to update authorized family members and guardians of infected residents at least once per day and upon a change in a resident's condition and at least once a week to update all residents and authorized families and guardians on the number of infections and deaths at the facility, by electronic or such other means as may be selected by each authorized family member or guardian; and

(b) that includes a method to provide all residents with daily access,

At no cost, to remote videoconference or equivalent communication methods with family

members and guardians; and

(ii) protection plans against infection for staff, residents and families, including:

(a) a plan for hospitalized residents to be readmitted to such residential health care facility

after treatment, in accordance with all applicable laws and regulations; and

(b) a plan for such residential health care facility to maintain or contract to have at least a

two-month supply of personal protective equipment; and

(iii) a plan for preserving a resident's place in a residential healthcare facility if such resident

is hospitalized, in accordance with all applicable laws and regulations.

(b) the residential health care facility shall prepare and comply with the pandemic

emergency plan. Failure to do so shall be a violation of this subdivision and may be subject to

civil penalties pursuant to section twelve and twelve-b of this chapter.

The commissioner shall review each residential healthcare facility for compliance with its plan

and the applicable regulations in accordance with paragraphs (a) and (b) of subdivision one

of this section.

(c) within thirty days after the residential health care facility's receipt of written notice of

noncompliance such residential healthcare facility shall submit a plan of correction in such

form and manner as specified by the commissioner for achieving compliance with its plan and

with the applicable regulations. The commissioner shall ensure each such residential

healthcare facility complies with its plan of correction and the applicable regulations.

(d) the commissioner shall promulgate any rules and regulations necessary to implement the

provisions of this subdivision.

§ 2. This act shall take effect immediately.

1. Communicable Disease Reporting:

1.1. Importance of Reporting

NYSDOH is charged with the responsibility of protecting public health and ensuring the

safety of health care facilities.

Reporting is required to detect intra-facility outbreaks, geographic trends, and identify

emerging infectious diseases.

The collection of outbreak data enables the NYSDOH to inform health care facilities of

potential risks and preventive actions.

Reporting facilities can obtain consultation, laboratory support and on-site assistance in

outbreak investigations, as needed.

1.2. What must be reported?

NYSDOH Regulated Article 28 nursing homes:

Reporting of suspected or confirmed communicable diseases is mandated under the New York State Sanitary Code (10 NYCRR 2.10), as well as by 10 NYCRR 415.19.8

Any outbreak or significant increase in nosocomial infections above the norm or baseline in nursing home residents or employees must be reported to NYSDOH. This can be done electronically via the Nosocomial Outbreak Reporting Application (NORA). NORA is a NYSDOH Health Commerce System Application. Alternately, facilities may fax an Infection Control Nosocomial Report Form (DOH 4018) on the DOH public website.

Facilities are expected to conduct surveillance that is adequate to identify background rates and detect significant increases above those rates. Healthcare associated infection outbreaks may also be reported to the LHD.

A single case of a reportable communicable disease or any unusual disease (defined as a newly apparent or emerging disease or syndrome that could possibly be caused by a transmissible infectious agent or microbial toxin) must be reported to the local health department (LHD) where the patient/resident resides. In addition, if the reportable communicable disease is suspected or confirmed to be acquired at the NYSDOH regulated Article 28 nursing home, it must also be reported to the NYSDOH. This can be done electronically via the NORA, or, by faxing an Infection Control Nosocomial Report Form (DOH 4018).

Reports must be made to the local health department in the county in which the facility is located (as the resident’s place of residence) and need to be submitted within 24 hours of diagnosis. However, some diseases warrant prompt action and should be reported immediately by phone.

Categories and examples of reportable healthcare-associated infections include:

An outbreak or increased incidence of disease due to any infectious agent (e.g.

staphylococci, vancomycin resistant enterococci, Pseudomonas, Clostridioides

difficile, Klebsiella, Acinetobacter) occurring in residents or in persons working in the

facility.

Intra-facility outbreaks of influenza, gastroenteritis, pneumonia, or respiratory

syncytial virus.

Foodborne outbreaks.

Infections associated with contaminated medications, replacement fluids, or

commercial products.

8 A list of diseases and information on properly reporting them can be found below.

https://www.health.ny.gov/forms/doh-4018.pdf


https://www.health.ny.gov/forms/instructions/doh-389_instructions.pdf



Single cases of healthcare-associated infection due to any of the diseases on the

Communicable Disease Reporting list. For example, single cases of nosocomial

acquired Legionella, measles virus, invasive group A beta hemolytic Streptococcus.

A single case involving Staphylococcus aureus showing reduced susceptibility to

vancomycin.

Clusters of tuberculin skin test conversions.

A single case of active pulmonary or laryngeal tuberculosis in a nursing home

resident or employee.

Increased or unexpected morbidity or mortality associated with medical devices,

practices or procedures resulting in significant infections and/or hospital admissions.

Closure of a unit or service due to infections.

Additional information for making a communicable disease report:

Facilities should contact their NYSDOH regional epidemiologist or the NYSDOH

Central Office Healthcare Epidemiology and Infection Control Program for general

questions and infection control guidance or if additional information is needed about

reporting to NORA. Contact information for NYSDOH regional epidemiologists and

the Central Office Healthcare Epidemiology and Infection Control Program is located

here:

https://www.health.ny.gov/professionals/diseases/reporting/communicable/infection/r

egional_epi_staff.htm. For assistance after hours, nights and weekends, call New

York State Watch Center (Warning Point) at 518-292-2200.

Call your local health department or the New York State Department of Health's

Bureau of Communicable Disease Control at (518) 473-4439 or, after hours, at 1

(866) 881-2809; to obtain reporting forms (DOH-389), call (518) 474-0548.

For facilities in New York City:

o Call 1 (866) NYC-DOH1 (1-866-692-3641) for additional information.

o Use the downloadable Universal Reporting Form (PD-16); those belonging to

NYC MED can complete and submit the form online.

2.0. PEP Communication Requirements

As per the requirements of the PEP, a facility must develop external notification procedures

directed toward authorized family members and guardians of residents.

To adequately address this requirement, the facility will need to develop a record of all

authorized family members and guardians, which should include secondary (back-up)

authorized contacts, as applicable.

Under the PEP, facilities must include plans and/or procedures that would enable them to (1)

provide a daily update to authorized family members and guardians and upon a change in a

https://www.health.ny.gov/professionals/diseases/reporting/communicable/infection/regional_epi_staff.htm



https://www1.nyc.gov/assets/doh/downloads/pdf/hcp/urf-0803.pdf

http://www.nyc.gov/health/nycmed

resident's condition; and (2) update all residents and authorized families and guardians at least

once per week on the number of pandemic-related infections and deaths, including residents

with a pandemic-related infection who pass away for reasons other than such infection (e.g.,

COVID positive residents who pass away for reasons other than COVID-19).

Such updates must be provided electronically or by such other means as may be selected by

each authorized family member or guardian. This includes a method to provide all residents with

daily access, at no cost, to remote videoconference or equivalent communication methods with

family members and guardians.

3.0 PPE Infection Control Requirements

In addition to communication-related PPE requirements address above, the facility must develop pandemic infection control plans for staff, residents, and families, including plans for (1) developing supply stores and specific plans to maintain, or contract to maintain, at least a two- month (60 day) supply of personal protective equipment based on facility census, including consideration of space for storage; and (2) hospitalized residents to be admitted or readmitted to such residential health care facility or alternate care site after treatment, in accordance with all applicable laws and regulations, including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); 42 CFR 483.15(e) and 42 CFR § 483.80. .

Additional infection control planning and response efforts and that should be addressed include:

Incorporating lessons learned from previous pandemic responses into planning efforts to

assist with the development of policies and procedures related to such elements as the management of supplies and PPE, as well as implementation of infection control protocols to assist with proper use and conservation of PPE.

All personal protective equipment necessary for both residents and staff in order to continue to provide services and supports to residents. COVID-specific guidance on optimizing PPE and other supply strategies is available on CDC’s website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. Supplies to be maintained include, but are not limited to:

N95 respirators;

Face shield;

Eye protection;

Gowns/isolation gowns;

gloves;

masks; and

sanitizers and disinfectants (EPA Guidance for Cleaning and Disinfecting):

Other considerations to be included in a facility’s plans to reduce transmission regard when there are only one or a few residents with the pandemic disease in a facility:

Plans for cohorting, including:

Use of a part of a unit, dedicated floor, or wing in the facility or a group of rooms at the end of the unit, such as at the end of a hallway.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html

https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19f

IT/Communications systems failure can impact the following critical systems: computer

network; telephone network; on-site data storage; medical devices; medication

replenishment; and HVAC system.

An IT/communications failure incident may hinder standard notification methods. Alternate

forms of notification with staff, residents and external agencies include: pagers, hand-held

radios, runners, personal cell phones, and social media.

Discontinue any sharing of a bathroom with residents outside the cohort

Proper identification of the area for residents with COVID-19, including demarcating reminders for healthcare personnel; and

Procedures for preventing other residents from entering the area.

4.0 Other PEP Requirements

PEP further requires that facilities include a plan for preserving a resident’s place at the facility when the resident is hospitalized. Such plan must comply with all applicable State and federal laws and regulations, including but not limited to 18 NYCRR 505.9(d)(6) and 42 CFR 483.15(e).

Hazard Annex L: IT/Communications

Failure

Preparedness

Utilize cloud-based or off-site servers to store data that also meet resident confidentiality requirements.

Provide staff with training on use of facility computers and potential risks of personal use (e.g., opening attachments from unknown senders).

Ensure redundant communications mechanisms:

Consider procurement of handheld radios or walkie-talkies.

Store paper-based versions of critical forms and documentation, including contact

lists.

Identify and protect resident care systems and records, including resident management systems, medical/resident records, resource availability, etc.

Identify and protect clinical support systems including:

Computer desktops, laptops, and tablets at nursing stations, hallways, bedside,

laptops, etc.

Electronic and automatic transfer of information between IT systems, dietary, etc.

Identify and protect administrative systems including:

Telephones, fax machines, databases, networks, wireless network, modems, etc.

Fire protection systems, security access, external email, website, etc.

Response

Implement the facility’s business continuity plan, if one exists.

If the disruption is deliberate, contact local law enforcement, the Federal Bureau of Investigation’s Cyber Division, and the state cyber terrorism division, as appropriate.

Conduct a risk assessment of affected environmental systems (e.g., utilities) and implement plans to maintain affected systems that support operations. If necessary, consider the implementation of a protective action. Refer to Annex A: Protective Actions in the Base Plan for more information.

Isolate and repair, replace, or remove affected systems from the facility network.

Address social media issues as warranted and use social media for messaging as situation dictates.

Implement manual documentation systems (e.g., paper-based systems).

Implement manual inventory and resupply processes, including medication distribution.

In the event of heating or air conditioning system failure and/or failure of medical devices, it may be necessary to evacuate some or all residents. If the decision is made to evacuate, please refer to the NYSDOH Evacuation Plan Template.

Landslides occur when masses of rock, earth, or debris move down a slope. Mudslides, also

known as debris flows, are a fast-moving landslide. Landslides can occur within mere

minutes and can travel several miles. Hazards associated with landslides include:

Rapidly moving water and debris that can lead to injury;

Broken electrical, water, gas, and sewage lines that can result in injury or illness;

and

Disrupted roadways and railways that can endanger motorists and disrupt transport

and access to health care.

Hazard Annex M: Landslide

Preparedness

Evaluate the facility for landslide hazards (e.g., recent wildfires or other incidents that have destroyed ground cover, which mitigates against landslides).

Ensure structures are in full compliance with regional building codes.

Educate staff on landslide warning signs, including:

Springs or saturated ground in areas that are not usually wet.

Bulges in the ground; buckling in the ground.

Increasing space between soil and foundations.

Cracks in foundation.

Response

If indoors, staff and residents should take cover under desks, tables, or other heavy pieces of furniture. Residents with wheelchairs should be told to lock their wheels. If outdoors, staff and residents should get out of the path of the mudflow and get to high ground.

Monitor surrounding area for flooding.

Direct emergency response personnel to possible victims.

Check building and surrounding area for damage or other safety issues once given the ―all clear‖ by emergency response personnel.

Listen to local radio and TV for emergency information and updates.

Report broken utilities and damaged roadways to local authorities.

Loss of electrical services may be the result of natural disasters, industrial accidents at

power generation facilities, or damage to power transmission systems. Natural hazards and

weather-related incidents that often cause with power outages include: coastal storms;

floods; tornados; and blizzards/ice storms.

Hazard Annex N: Power Outage

Preparedness

Regularly inspect and test all generators involved in supplying emergency power to areas for resident care and ensure the facility has sufficient fuel on-site to fuel the generator.

See Hazard Annex L: IT/Communications Failure for additional preparedness activities.

Response

Assess the situation. Consult decision support considerations (information and intelligence, anticipated impacts, resources).

Maintain contact and communication with the utility company, County Office of

Emergency Management, and Health Emergency Preparedness Coalition to receive utilities restoration reports.

Based on facility decision-making criteria, consider the implementation of a protective action. Refer to Annex A: Protective Actions in the Base Plan for more information. If the decision is made to evacuate, refer to the NYSDOH Evacuation Plan Template.

Continually seek updates from staff on both staff and resident well-being to determine if other protective actions are needed for some or all of the facility’s population.

The emergency generator will start automatically within 7 seconds of an outage.

If the emergency generator does not start automatically, notify the Plant Manager. If necessary, attempt to start the generator manually by following instructions posted at inside cab of the door.

Use available flashlights as temporary sources of light. These can be found at emergency box at the nursing stations and maintenance emergency supply.

Take all reasonable steps to protect food and water supplies and maintain a safe environment of care for residents and staff.

A tornado is a violently rotating column of air touching the ground, usually attached to the

base of a thunderstorm. Winds of a tornado may reach 300 miles per hour. Damage paths

can be in excess of one mile wide and 50 miles long.

Hazard Annex O: Tornado

Preparedness

Develop procedures for quickly moving residents away from spaces with flat, wide- span roofs (e.g. cafeterias, auditoriums), which can collapse in the event of a tornado.

Train staff on what not to do during a tornado, e.g. move to higher floors or shelter in corners, both of which are dangerous.

Monitor local news and radio outlets for tornado watches or warnings issued by the National Weather Service.

Response

If a tornado watch is issued:

Ensure all residents and assigned staff are inside the facility and accounted for.

Check outdoors and indoors for any objects that might become projectiles.

Ensure that windows are kept tightly closed.

Move residents, staff, and visitors away from windows, skylights, and exterior walls,

as possible.

After tornado impact, assign staff to assess residents for any injuries that require immediate attention. Encourage staff to keep residents as calm as possible.

Survey the facility for injuries, structural damage, fire, ruptured gas or water pipes, etc. If necessary, shut off utility lines and/or panels.

Look for electrical system damage. If there are sparks or broken or frayed wires, or the smell of hot insulation, turn off the electricity at the main fuse box or circuit breaker. If you have to step in water to get to the fuse box or circuit breaker, call an electrician before proceeding. Panel(s) can be found at back north corner of ground floor ( near laundry room)

Wildfires threatening the facility may emerge with or without warning, however a wildfire

evacuation will most likely occur very quickly, as opposed to a coastal storm.

Hazard Annex P: Wildfire

Preparedness

Implement wildfire protection measures:

Clean roof surfaces and gutters

Use only fire-resistant materials on the exterior of the facility

Consider fire-resistant landscaping

Response

Maintain contact and communication with County Office of Emergency Management or Health Emergency Preparedness Coalition to receive wildfire-related updates.

Monitor local news for evacuation reports and instructions.

Based on facility decision-making criteria, consider the implementation of a protective action. Refer to Annex A: Protective Actions in the Base Plan for more information.

In case of immediate threat, move residents to a pre-designated staging area for rapid

evacuation. If a gas leak is suspected, notify the Plant Manager.

Preemptive methods to mitigate smoke and fire risk:

Close all windows, doors, and vents.

Limit the amount of foot traffic in and out of the facility.

Do not allow residents outside, as possible.

If using heating or air conditioning, set to re-circulate indoor air to shut down exterior

air intakes.

Regularly seek updates from staff to determine if protective actions are needed for some or all of the facility’s population. If the decision is made to evacuate, refer to the NYSDOH Evacuation Plan Template.

Monitor residents and staff for complications related to smoke exposure.